Get the free CHIP Coverage Coordination Disclosure Form - cms

This form is used by a plan administrator to disclose information about group health plan coverage under the Children's Health Insurance Program, aiming to facilitate coordination and evaluate cost-effectiveness

How to fill out chip coverage coordination disclosure

How to fill out CHIP Coverage Coordination Disclosure Form

1. Obtain the CHIP Coverage Coordination Disclosure Form from the appropriate agency or website.
2. Enter the child's personal information, including name, address, and date of birth.
3. Fill in the insurance information for any other coverage the child may have, including policy numbers and names of insurance providers.
4. Provide details about the parent's or guardian's employment, if applicable.
5. Sign and date the form, ensuring all information is accurate and complete.
6. Submit the completed form to the appropriate CHIP program office for processing.

Who needs CHIP Coverage Coordination Disclosure Form?

1. Families applying for CHIP coverage who have other health insurance.
2. Parents or guardians of children with existing medical coverage that may coordinate with CHIP benefits.
3. Individuals seeking to ensure proper coverage for a child when multiple insurances are involved.

For pdfFiller’s FAQs

What is CHIP Coverage Coordination Disclosure Form?

The CHIP Coverage Coordination Disclosure Form is a document required for reporting information about health coverage that coordinates with the Children's Health Insurance Program (CHIP), facilitating proper coordination of benefits.

Who is required to file CHIP Coverage Coordination Disclosure Form?

Entities such as health care providers, insurance companies, and Medicaid agencies that provide coverage to children under CHIP are required to file the CHIP Coverage Coordination Disclosure Form.

How to fill out CHIP Coverage Coordination Disclosure Form?

To fill out the CHIP Coverage Coordination Disclosure Form, gather all necessary information about the child's health coverage, including policy numbers, coverage dates, and any other relevant data, then accurately input this information into the form following the provided guidelines.

What is the purpose of CHIP Coverage Coordination Disclosure Form?

The purpose of the CHIP Coverage Coordination Disclosure Form is to ensure that CHIP can coordinate benefits with other insurance providers, ensuring that children receive the appropriate health care coverage without duplication.

What information must be reported on CHIP Coverage Coordination Disclosure Form?

The CHIP Coverage Coordination Disclosure Form must report information such as the child's identifying information, details about any other health coverage the child may have, including coverage types and policy numbers, and the duration of such coverage.