| Accident/Injury Report 378.6 KB | Use this form to report information regarding an accident or injury for claim processing. |
| Appeal Request Form 121.61 KB | Ask IHN to change a decision made about your medical coverage. |
| Authorized Representative Form 64.19 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). |
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Medication Exception
285.79 KB
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Request medically necessary medications that are not normally covered on our formulary. Or request medications that request prior authorizations. |
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Primary Care Provider (PCP) Change Card
80.33 KB
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Choose or change your primary care provider. |
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Prior Authorization - Referral Form
23.95 KB
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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. |
