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PrintResetDurable Medical Equipment and Medical Supplies General Prescription and Medical Necessity Review Form Date of Delivery Sections 15 must be completed by the DME provider. Sections 4A, 4B,
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How to fill out ihcp-dme-provider-enrollment-and-maintenance-formpdf

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How to fill out ihcp-dme-provider-enrollment-and-maintenance-formpdf

01
Download the IHCP DME Provider Enrollment and Maintenance Form from the official website.
02
Read the instructions carefully to understand the requirements.
03
Fill out the provider information section, including the name, address, and contact details.
04
Provide the national provider identifier (NPI) number.
05
Complete the section regarding the type of services offered by the DME provider.
06
Attach any necessary supporting documents, such as proof of ownership or certification.
07
Review the form for accuracy and completeness.
08
Sign and date the form before submission.
09
Submit the form through the designated submission method, either by mail or electronically.

Who needs ihcp-dme-provider-enrollment-and-maintenance-formpdf?

01
Durable Medical Equipment (DME) providers seeking to enroll in the Indiana Medicaid program.
02
New DME providers wanting to establish eligibility for reimbursement.
03
Existing DME providers needing to update their enrollment information or maintain their status with the program.
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The IHCP DME Provider Enrollment and Maintenance Form is a document used by Durable Medical Equipment (DME) providers to enroll and maintain their information in the Indiana Health Coverage Programs (IHCP).
DME providers who wish to participate in the Indiana Health Coverage Programs must file the IHCP DME Provider Enrollment and Maintenance Form.
To fill out the IHCP DME Provider Enrollment and Maintenance Form, providers must complete all required sections with accurate information, including provider details, services offered, and any necessary supporting documentation.
The purpose of the form is to facilitate the enrollment process for DME providers in the IHCP, ensuring they meet all requirements to provide services to patients covered under these programs.
The form requires reporting of details such as the provider's name, address, Tax Identification Number (TIN), National Provider Identifier (NPI), types of services provided, and any necessary legal documentation.
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