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PROVIDER AGREEMENT Children's Special Health Care Services (CSHCS) Maximum Caseload Addendum
State Form 51399 (7-03) Indiana State Department of Health

I/We choose to accept no more than ____ active cases with the Children's Special Health Care Services Program, at this time.

Provider DBA Name ____________________________________________ Officer Name _________________________________________________ Title __________________ Signature _________________________________________________ Date __________________ ISDH Provider ID _________________

Telephone Number _______________________________

Do not complete this form unless you wish to limit the number of patients you accept, which are participants in the Children's Special Health Care Services Program.

ISDH ­ Provider Relations Provider Agreement Maximum Case Load Addendum - CSHCS

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