Common Contracts
2 similar Provider Enrollment Agreement contracts
This agreement must be completed, signed, and returned to the IHCP for processing.Provider Enrollment Agreement • May 5th, 2020
By execution of this Agreement, the undersigned entity (“Provider”) requests enrollment as a provider in the Indiana Health Coverage Programs (“IHCP”). As an enrolled provider in the IHCP, the undersigned entity agrees to provide covered services and/or supplies to Indiana Health Coverage Program members
This agreement must be completed, signed, and returned to the IHCP for processing.Provider Enrollment Agreement • October 12th, 2017
By execution of this Agreement, the undersigned entity (“Provider”) requests enrollment as a provider in the Indiana Health Coverage Programs (“IHCP”). As an enrolled provider in the IHCP, the undersigned entity agrees to provide covered services and/or supplies to Indiana Health Coverage Program members
