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:

  1. becoming certified through the Medicaid Waiver program administered through the Indiana Division of Aging,
  2. obtaining a license from the Indiana State Department of Health,
  3. 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

If you have questions, please email