Indiana Medicaid Promoting Interoperability Program Enrollment Questionnaire

To express your interest in enrolling in the Indiana Medicaid PI Program, please provide your contact information and fill out this 13-question form.

About your Organization

Provide number of sites, and any comments regarding the sites.

Potential "Eligible Providers" under the Indiana Medicaid MU Program are Physicians (MDs & DOs); Nurse Practitioners; Certified Nurse Midwives; Dentists; and Physician Assistants who lead an FQHC or an RHC.

Health IT Questions

Next Steps

Once you submit this form, your clinic/small practice will be included on our list of organizations interested in participating in the program. A representative from Purdue Healthcare Advisors will get back to you shortly regarding your interest.

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