Contact Us
|
FAQs
|
Login
Logout Confirmation
Are you sure you want to logout?
Logout Confirmation
If you navigate away from this page, you will lose unsaved data. Are you sure you want to logout?
Home
Home
>
Registration
Wednesday 07/02/2025 10:33 PM
Registration Step 1 of 2 - Personal Information
*
Indicates a required field.
Please provide the following information to get started!
*
First Name
First Name is a required field.
The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"].
*
Last Name
Last Name is a required field.
The text field contains invalid characters. Acceptable characters include [a-z], [A-Z], [0-9], spaces and characters [.?!,()-_+';:"].
*
Birth Date
Birth Date is a required field.
Birth Date is not in the correct format, enter the value in the format 'MM/DD/YYYY'.
*
Last 4 of Driver's License Number
Last 4 of Driver's License Number is a required field.
*
Delegate Code
Delegate Code is a required field.
© 2025 Indiana Medicaid | R4.2 |
Privacy Policy
|
Medicaid Provider Home Page
