Forms.chpw.org

Clinic Selection Form

WebThis form supplies Community Health Plan with the information needed to assign members to the correct clinic. This form also gives you the opportunity to request clinic assignment …

Actived: 9 days ago

URL: https://forms.chpw.org/clinic-selection

Medicare Plan Review Request Form

WebPhone ‒ Receive a call from one of our licensed Medicare experts to talk about your options In person ‒ Meet with one of our licensed Medicare experts at a clinic near you (requires …

Category: Health Go Health

Well-Child Program Form

WebThe Member ID, Name, and Date of Birth you enter must match exactly what is on the member’s CHPW ID card. The Age Group field refers to the age group found on the well …

Category: Health Go Health

Prenatal Program Form

WebWe want to reward parents for keeping up with the doctor visits that help their babies stay healthy. Our Prenatal Program is open to pregnant individuals who are CHPW members …

Category: Health Go Health

CHPW Local Health Insurance

WebPlease select the appropriate provider form. Annual MOC SNP Model of Care Form Annual Notice of Change Electronic Opt-in Apple Health Join Clinic and Group Changes Form …

Category: Health Go Health

Provider Ownership and Control Interest Disclosure Form

WebThe federal regulations set forth in 42 CFR §455.100 - §455.106 require providers to disclose to the U.S. Department of Health and Human Services, the State Medicaid …

Category: Health Go Health

Provider Directory Intake Form

WebAs a health plan, we are committed to regularly reviewing our provider directory for our Medicare and Medicaid (Washington Apple Health and Integrated Managed Care) …

Category: Health Go Health

CHPW Medicare Advantage Enrollment Application

WebCommunity Health Plan of Washington is a HMO plan with a Medicare contract and a contract with the Washington State Medicaid program. Enrollment in Community Health …

Category: Health Go Health

Medicare Plan Review Request Form

WebPhone ‒ Receive a call from one of our licensed Medicare experts to talk about your options In person ‒ Meet with one of our licensed Medicare experts at a clinic near you (requires …

Category: Health Go Health

Annual Notice of Change Electronic Opt-in

WebWelcome, and thank you for going green! Signing up for electronic delivery means you’re saving paper and helping the environment. By completing this form, you agree to have …

Category: Health Go Health

Provider Enrollment Request Form

WebDoes your business have a signed Core Provider Agreement (CPA) with the WA State Health Care Authority (HCA) to see Medicaid Patients? Either CPA or Non-Billing …

Category: Health Go Health

General Compliance, Fraud, Waste and Abuse (GCFWA) …

WebCommunity Health Plan of WA (CHPW) is required by contract with the Centers for Medicare & Medicaid Services (CMS) and the Washington State Health Care Authority …

Category: Health Go Health

Request for Redetermination of Medicare Prescription Drug Denial …

WebImportant Note: Expedited Decisions . If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain …

Category: Health Go Health

Renew My Apple Health Plan

WebBy submitting this form, I verify this is my phone number and email address and consent to be contacted via phone, text messages, and/or email messages regarding plan renewal …

Category: Health Go Health

Procedure Code Lookup Tool

WebThis tool does not guarantee payment. Eligibility verification is required. Member must be covered as of the time/date of service. Failure to obtain the required prior authorization …

Category: Health Go Health

Provider Changes Form

WebSelect Areas of Expertise: Abuse Addiction Medicine Aggression Replacement Therapy Alcohol and Drug Information School Anger Anxiety Attention Deficit Disorders Autism …

Category: Medicine Go Health

Community Health Plan of Washington

Web1.Please enter all details about the incident. Include as much detail as possible. Thorough information will aid investigation. 2.Compile any relevant documentation and add as …

Category: Health Go Health

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