Provider Maintenance

The PMP Profile Change Request Form must be completed and submitted to MDwise Hoosier Alliance for any Primary Medical Provider (PMP) with a profile change. The following changes can be completed using this form:

• Panel updates and changes
• Dis-enrollment with re-enrollment
• Dis-enrollment/termination

Completed forms can be mailed or faxed to:

MDwise Hoosier Alliance
Attn: Provider Maintenance
5604 Fortune Circle Drive, Suite N
Indianapolis, IN 46241
Fax: 866-465-2985

If you have questions regarding this form please contact Provider Maintenance at 888-961-3100.

PMP Profile Change Request Form. This document must be submitted on office letterhead or with the practice/group logo at the top of form.