CIHCP Handbook
Click here to download the complete CIHCP Handbook (PDF) or select a section below.
Forms and Instructions
- Form 100 - Application for Health Care Assistance (PDF)
- Form 100 A - Application for Health Care Assistance Jail Application (PDF)
- Form 101 - Worksheet (PDF)
- Form 101 A - Report of Changes (PDF)
- Form 102 - Appointment Notice (PDF)
- Form 103 - Request for Information (PDF)
- Form 104 - Health Care Services Record (PDF)
- Form 105 - CIHCP Monthly Financial Report (PDF)
- Form 106 - Eligibility Dispute Resolution Request (PDF)
- Form 108 - Case Record Information Release (PDF)
- Form 109 - Notice of Eligibility (PDF)
- Form 110 - Claim Processing Notification (PDF)
- Form 111 - Facility Payment Rate Request (PDF)
- Form 117 - Notice of Ineligibility (PDF)
- Form 120 - Optional Health Care Services Notification (PDF)
- Form 128 - Employment Verification (PDF)
- Form 149 - Statement of Self-Employment Income (PDF)
- Form 300 - End of Year Report (PDF)
- Form 500 - Request for State Assistance Funds (90 percent) (PDF)
- Form 500 A - Request for State Assistance Funds (100 percent) (PDF)