Hoosier Alliance is an AmeriHealth Mercy Company
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Provider Home > Providers > Provider Communications > Provider Maintenance
General Program Overview

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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.

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

 
 
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