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Your Forms

Here are some forms you or your provider may need. These forms relate to your coverage.

Appeal Request Form 131.9 KB   Ask IHN to change a decision made about your medical coverage.
Authorized Representative Form 26.1 KB   You have the right to choose an Authorized Representative. This person has your permission to discuss your health information with IHN.
Dental Plan Choice Card 66.02 KB   Choose or change your dental plan. 
Hearing Request Form
Request an administrative hearing from the Department of Medical Assistance Programs (DMAP). 
Medication Exception 45.57 KB
Request medically necessary medications that are not normally covered on our formulary. Or request medications that request prior authorizations.
Primary Care Provider (PCP) Change Card 80.33 KB
Choose or change your primary care provider. 
Prior Authorization - Referral Form 23.95 KB
Request a prior authorization for medical services you want IHN to cover. 
Request for Health Plan Records Form 22.84 KB   Request any health plan documentation from us.