To begin the process of becoming an Area 9 contracted provider, download the PDF file below and then complete four signed copies of the contract along with other pertinent documents, such as Certificate of Liability Insurance, noted on the bottom of the Fee For Service Agreement and return to us by mail. Please contact our ADRC Director for further information by calling (765)966-1795 or (800)458-9345.
The Area 9 contract consists of three parts: the Memorandum of Agreement, the Attachment A, and the Fee for Service Agreement, as well as other noted documents to process your contract. We also need a copy of the IU Provider Information/W-9 form. Click on each link below and print out a copy of each of these required documents.
*Note on the Fee For Service Agreement that you also need to submit a packet (one copy only) containing the following:
- Copy of license, if applicable
- Copy of Medicaid Waiver Provider certification (all CHOICE providers must be certified as Indiana Medicaid Waiver Providers as of April 1, 2004)
- Copy of most recent State Board of Health Review, if applicable
- Copy of Certificate of Liability Insurance
- Copy of provider's brochure
- Board of Directors listing, including addresses (Title III, SSBG only)
- Graphic representation of organizational structure (Title III, SSBG only)
The link below provides some information on setting up your billing status with HP to facilitate payments.
Contact information for state provider enrollment services: