CHOICE Provider Profile Form
Use this form to get started as a CHOICE provider, or update your current information.
Current providers can submit updated contact information via this form at any time.
New providers may complete this form after:
- becoming certified through the Medicaid Waiver program administered through the Indiana Division of Aging,
- obtaining a license from the Indiana State Department of Health,
- and attending a CHOICE Information Session with the CICOA Provider Specialist.
For full details on the provider application process, visit the Become a Provider page.
Alternatively, you may complete a PDF Provider Profile form and send it to provider@cicoa.org.
If you have questions, please email provider@cicoa.org.