Change Accepting New Member Status

Provider Name

First Name *

Last Name *

Provider NPI # *

Tax ID # *

Group Name *

Group NPI # *

Group Medicaid Number * Please write Ambetter Only in this box if not enrolled with IHCP

Service Location Address

Street Address *

Address Line 2

City *

ZIP / Postal Code *

State *

Provider Type (Choose one) *

Primary Care Provider (PMP) Specialist

Is Provider Accepting New Members *

Yes No

Programs to Update (Choose all that apply) *

Hoosier Healthwise (HHW) Healthy Indiana Plan (HIP) Hoosier Care Connect (HCC) Ambetter from MHS Wellcare by Allwell & Wellcare Complete

Comments

Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone *

Last Updated: 01/24/2024