CHP Forms 2018-12-05T15:48:09+00:00

CHP Forms

1

Demographic Changes / Additions

CHP Change/Add Form 

Complete this form at least 90 days prior for all changes. Submit populated CMS1500 and W9 for all changes.

Click Here

CMS 1500

Submit with demographic information populated. Payors require this information to ensure proper billing set up.

Click Here

W-9

Complete to match your IRS filing.

Click Here

2

Other Forms

Allied Health

Complete this form if your office employs any allied health providers such as a PA, ARNP’s

Click Here

Medicare/Medicaid Participation

Complete this form for Medicare/Medicaid participation tracking.

Click Here

Request for Contact Information

Complete this form so we can notify you via email.

Click Here

Claim Inquiry Form

Complete this form for any claim issues you may be experiencing.

Click Here