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CIHCP Handbook & Forms

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CIHCP Handbook & Forms

CIHCP Handbook

Click here to download the complete CIHCP Handbook (PDF) or select a section below.

  • Section 1 - Program Administration (PDF)
  • Section 2 - Eligibility Criteria (PDF)
  • Section 3 - Case Processing (PDF)
  • Section 4 - Service Delivery (PDF)
  • Section 5 - State Assistance Fund (PDF)
  • Section 6 – Supplemental Security Income Reimbursement (PDF)

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)

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