Provider Profile Form

Use this form to get started as a 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, as well as obtaining a license from the Indiana State Department of Health. 

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