PMP Term

Primary Medical Provider (PMP) NPI # *

Primary Medical Provider (PMP) Name

First Name *

Last Name *

Degree *

Tax ID # * Practitioner will be termed from all locations associated with this TIN

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 *

Date Term Effective *

Other (Reason)

Programs to Term (choose all that apply) * Healthy Indiana Plan (HIP) Hoosier Care Connect (HCC) Hoosier Healthwise (HHW) Ambetter from MHS Wellcare by Allwell & Wellcare Complete Behavioral Health

Update Requested By:

First Name *

Last Name *

Date *

Contact Email *

Contact Phone Number *

Move Members To (choose one): * Auto-Assignment Provider

If the accepting provider is not a current MHS panel holding PMP, and/or the panel size or age restrictions cannot accommodate individual members being assigned to the requested provider, the members will be auto assigned.

Provider #1 NPI *

Provider #1 TIN *

Provider #1 First Name *

Provider #1 Last Name *

Provider #2 NPI

Provider #2 TIN

Provider #2 First Name

Provider #2 Last Name

Provider #3 NPI

Provider #3 TIN

Provider #3 First Name

Provider #3 Last Name

Last Updated: 01/24/2024