Written by a parent, not a doctor. Nothing here is medical advice.

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Indiana Department of Health

Children's Special Health Care Services

What you get

Covered services may include specialty care, prescriptions, dental care, diagnostic care, referrals, and travel reimbursement. The amount isn't published. Ask. Open now.

Who starts it
You, with their part of the form from your doctor
How it’s sent
By post
Your time
About 15 minutes, plus waiting for the form
Last checked
Aug 27, 2026

Before you start, check you fit

  • Your child is 21 or under.
  • The diagnosis must also satisfy the program’s severe chronic-condition criteria.
  • Coverage is limited to approved condition-related services.

  1. Ask your doctor for their part of the formStart here. This is the part that takes the longest.

    Indiana Department of Health needs 2 things from your doctor. Copy this message, or say it in person at the next visit.

    Hi [doctor’s name],

We’d like to apply to Indiana Department of Health’s Children's Special Health Care Services. Covered services may include specialty care, prescriptions, dental care, diagnostic care, referrals, and travel reimbursement. They are taking applications now.

They need 2 things from you: a signature on the form and a signed confirmation of the diagnosis. Their form and instructions are here: https://www.in.gov/health/cshcs/

Could you do that when you have a chance? I’ll bring the printed form to our next visit, or I can email it. Thank you for everything you do for us.

[your name] · [phone]
    Copying is the only thing this page does with your text. Nothing is saved.

  2. Fill in their formPrint it, or fill it in on screen if the PDF allows.

    Open the application PDF ↗ Checked Aug 27, 2026

    What the form asks for

    Family and applicant portions of State Form 49006
    County of Residence of Applicant; Application Date (mm/dd/yyyy)Is parent/guardian/or applicant in the U.S.A. on a VISA?; Is the applicant a Ward of the StateApplicant name, date of birth, prior name or nickname, sex, race, ethnicity, address, telephone, email, and primary languageMedical Condition applicant hasParent/Guardian name, address, home telephone, alternate telephone, and work telephonePersonnel Other Than Parent/Guardian/Applicant completing application: name, agency, address, telephone, and faxList all persons (including participant) who live in your home and provide requested information for each individualIncome verification and gross amount/how often received for each household income sourceIf you have no income, how do you pay your bills? (supply written and signed statements)Medical insurance information, coverage type, policyholder, insurer, policy and employer information; complete a new form for each coverageHealth care received in the past twelve (12) months: primary care, dentist, specialty physicians, hospitals/ER, reasons seen, and dates last seenAdaptive equipment; medical equipment or supplies; current medications with dose, frequency and purpose; special diet; additional commentsSignature of Applicant/Parent/Legal Guardian; Relationship to Applicant; DateAuthorization for collection of information; authorization for release of protected health information; authorization to release and share medical information
    Physician's Health Summary · your care team fills this in
    Applicant's Name; Date of Birth; Parent/GuardianBirth history, past hospitalizations/illnesses, present diagnosis/illnesses including ICD/DSM codes, medications, precautions, immunizations, physical status, vision, hearing, developmental screening, last visit, referrals, and recommendationsPhysician's Signature (Primary/Specialty Health Provider); Date; Physician's Name; Address/Telephone Number

    Have ready

    • Proof of Indiana residence.
    • Child's birth certificate.
    • Health-insurance information and a copy of each insurance card, front and back.
    • Income verification for every household member receiving income; preferred proof is the three most recent consecutive pay stubs, with published alternatives.
    • Proof that the family applied for Medicaid.
    • Signed enrollment agreement, data-collection authorization, HIPAA authorization, and medical-information release pages in the packet.

  3. Post your application and their part of the form togetherTo the address on the form.

    • Mail the complete signed packet and supporting copies to Indiana Department of Health, Children's Special Health Care Services, Section 5C, 2 North Meridian Street, Indianapolis, IN 46204.
    • Do not alter the application after it has been completed and signed.

After you send

Call 1-317-233-1351 or 1-800-475-1355, option 2, for enrollment questions or status follow-up. If you have not heard back in two weeks, write and ask whether it arrived.

Full record, as published