CIHCP Handbook and 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)