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

CHP Forms


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.

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CMS 1500

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

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Complete to match your IRS filing.

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Other Forms

Allied Health

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

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Medicare/Medicaid Participation

Complete this form for Medicare/Medicaid participation tracking.

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Request for Contact Information

Complete this form so we can notify you via email.

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Claim Inquiry Form

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

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