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  4. County Indigent Health Care Program
  5. CIHCP Handbook & Forms

CIHCP Handbook & Forms

CIHCP Handbook

Download the complete CIHCP Handbook or select a section below.

  • Section 1000 - Program Administration
  • Section 2000 - Eligibility Criteria
  • Section 3000 - Case Processing
  • Section 4000 - Service Delivery
  • Section 5000 - State Assistance Fund
  • Section 6000 – Supplemental Security Income Reimbursement

Forms and Instructions

  • 3064 - Application for Health Care Assistance
  • 3065 - Worksheet
  • 3066 - Report of Changes
  • 3067 - Appointment Notice
  • 3068 - Request for Information
  • 3069 - Health Care Services Record
  • 3072 - CIHCP Monthly Financial Report
  • 3073 - Eligibility Dispute Resolution Request
  • 3076 - Case Record Information Release
  • 3077 - Notice of Eligibility
  • 3078 - Claim Processing Notification
  • 3079 - Facility Payment Rate Request
  • 3080 – SSI Appellant Notification
  • 3081 - Appellant – Provider Assignment
  • 3082 - Notice of Ineligibility
  • 3083 - Optional Health Care Services Notification
  • 3084 - Employment Verification
  • 3085 - Statement of Self-Employment Income
  • 3086 - End of Year Report
  • 3087 - TMHP Confidentiality Agreement
  • 3088 - Request for State Assistance Funds (90 percent)
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