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Indiana Medicaid PI Program Enrollment Questionnaire

Indiana Medicaid PI Program Enrollment Questionnaire

Please fill out the following 13-question form to inquire about enrollment in the program.

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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