IU Health POF Online Upload

IU Health Provider Option Form Secure Submission

Upload your completed IU Health Provider Option Form

Before you submit your form, please complete the following steps:
o Print clearly and review your form to ensure it is complete.
o Confirm the date of screening is within the following date range: 12/1/2024 - 11/30/2025.
o Be sure to provide a valid email address so we can communicate with you regarding the status of your form.
o Ensure you have signed your form. Your signature is required.
Name*

First

Last
Email Address*
File*
Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.
Phone

This field is for validation purposes and should be left unchanged.