Form Guidelines and Form Set

The following forms and guidelines are recommended for organizing charts to meet all documentation requirements.  For additional information regarding provider responsibilities, please reference the Network Manual.

Forms which can be modified for individual offices are available as Microsoft Word documents, all other forms require Adobe Acrobat.

Universal Form Set

The following forms may be used for all health plans.  Required forms are bolded.  The remaining forms are provided as examples, which meet contract requirements for treatment record documentation.

Treatment Record Tips

Health Plan Specific Guidelines and Resources

CHIPA Contact Numbers:

800-779-3825

562-467-5555

CHIPA Fax Numbers by Department:

General

562-402-2666

888-659-7921

Claims

877-563-3480

Clinical/Case Management

877-803-3182

Network/Provider Relations

877-349-1135