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Indiana Chronic Disease Management Program
Referral Forms

 Note: The following pages offer the forms for use when a Provider refers a new member to the Indiana Chronic Disease Management Program (ICDMP).

The intent of these pages is to give the Provider easy access for download of referral forms.

To be eligible for the program, the member must be enrolled in the Primary Care Case Management (PCCM) population of the Medicaid Select program or of the Hoosier Healthwise program.

Fax referral forms to:
317-488-2463
Attention: Manager

 Currently, members in the following categories are excluded from participation:

·        Risk Based Managed Care
·        Spend-Down
·        590 (residents in State owned facilities)
·        Residential Care Assistance Program
·        Level of care (e.g. people in nursing homes or in waiver programs)
·        Patients with end-stage renal disease
·        Patients with organ transplantation
·        Individuals not currently eligible for Medicaid

 Any questions you may have about the enrollment forms, please call 1-866-311-3101 and ask to speak with the Manager.

REFERRAL FORM