Indiana Care Select Provider Forms

MDwise Provider Forms

Full Panel Add Form
Hold Panel Add Request Form
Pre-Birth Selection Form
Provider Request for Member Reassignment
Addendum
MCE Universal Provider Enrollment Form
Download the Universal Credentialing Form

First Amendment to the Addendum
Member Intervention Education Form
W-9 Request for Taxpayer Identification Number
Member Ward/Foster Doctor Change Address Form
Member Asthma Action Plan Form

Care Select

RBMC Primary Medical Provider Disenrollment Cover Form without Reenrollment
Managed Care PMP Disenrollment with Reenrollment Form
Managed Care PMP Panel Limit and Panel Hold Form

Prior Authorization

Universal Prior Authorization Form

Prior Authorization - System Update Request Form
Prior Review and Authorization Dental Request Form

Form Update NEW!

Providers Must Sign the MDwise Care Select First Amendment to the Addendum.

Pharmacy?

For pharmacy forms and resources, please visit the pharmacy area of our website.

Behavioral Health Forms

Behavioral Health Referral Form

Help Guide, When to Refer a Behavioral Health Provider

For more behavioral forms and resources, please visit the behavioral health area of our website

Questions?

Please contact MDwise Provider Relations at 1.800.356.1204 or 317.630.2831 if you are in the Indianapolis area.

 

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