Indigent Health Care Program Handbook Forms and Instructions

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List of CIHCP forms.

Download Files: The following files are available in Adobe Acrobat (.pdf) and MSWord (.doc) formats. Click on the links below to download.  PDF files require the Adobe Acrobat Reader for viewing. All PDF forms are now PDF fillable forms.

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Form 100 - Application for Health Care Assistance(175 kb .pdf) Form 100 (529 kb .doc)

Form 100 Instructions (20 kb .pdf)

Form 100 A - Application for Health Care Assistance - Jail Application Form 100-A (688 kb .doc)

Form 101- Worksheet (385 kb .pdf) Form 101 (407 kb .doc)

Form 101 Instructions (20 kb .pdf)

Form 101-A - Report of Changes (224 kb .pdf) Form 101-A (183 kb .doc)

Form 101-A Instructions (15 kb .pdf)

Form 102 - Appointment Notice (101 kb .pdf) Form 102 (551 kb .doc)

Form 102 Instructions (16 kb .pdf)

Form 103 - Request for Information (71 kb .pdf) Form 103 (443 kb .doc)

Form 103 Instructions (18 kb .pdf)

Form 104 - Health Care Services Record (35 kb .pdf) Form 104 (195 kb .doc)

Form 104 Instructions (17 kb .pdf)

Form 105 - CIHCP Monthly Financial Report (46 kb .pdf) Form 105 (201 kb .doc)

Form 105 Instructions (179kb .doc)

Form 106 - Eligibility Dispute Resolution Request with instructions (65 kb .pdf) Form 106 and Instructions (196 kb .doc)

Form 108 - Case Record Information Release (53 kb .pdf) Form 108 (194 kb .doc)

Form 108 Instructions (17 kb .pdf)

Form 109 - Notice of Eligibility (60 kb .pdf) Form 109 (397 kb .doc)

Form 109 Instructions (17 kb .pdf)

Form 110 - Claim Processing Notification (42 kb .pdf)

Form 110 Instructions (15 kb .pdf) Form 110 Instructions (203 kb .doc)

Form 111 - Facility Payment Rate Request (175 kb .pdf) Form 111 (529 kb .doc)

Form 111 Instructions (20 kb .pdf)

Form 117 - Notice of Ineligibilty (70 kb .pdf) Form 117 (217 kb .doc)

Form 117 Instructions (16 kb .pdf)

Form 120 - Optional Health Care Services Notification with Instructions (73 kb .pdf) Form 120 & Instructions (442 kb .doc)

Form 128 - Employment Verification (97 kb .pdf) Form 128 (284 kb .doc)

Form 128 Instructions (15 kb .pdf)

Form 149 - Statement of Self-Employment Income (103 kb .pdf) Form 149 (278 kb .doc)

Form 149 Instructions (15 kb .pdf)

Form 222 - Monthly Gross Income Screening Table (53 kb .pdf)

Form 222 Instructions (16 kb .pdf)

Form 300 - End of Year Report (41 kb .pdf) Form 300 (207 kb .doc)

Form 300 Instructions (56kb .doc)

Form 500 - Request for State Assistance Funds (90%) (pdf) Form 500 (210 kb .doc)

Form 500 Instructions (18 kb .pdf)

Form 500-A - Request for State Assistance Funds (100%) (pdf) Form 500-A (206 kb .doc)

Form 500-A Instructions (18 kb .pdf)

 

Last updated August 07, 2014