Get the free CHIP PH-95 REFERRAL COVER SHEET - services dpw state pa
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CHIP PH95 Referral Cover sheet TO:DHS/OIM/CENTRAL UNIT FAX: [717] 3460363DATE: ___FROM: ___ORGANIZATION: ___TELEPHONE: ___ORGANIZATION FAX: ___PID PROVIDER NO: P1712002CHIP CONTRACTOR MA PROVIDER
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How to fill out chip ph-95 referral cover
How to fill out chip ph-95 referral cover
01
Obtain the PH-95 referral cover form from the appropriate source.
02
Fill out all required fields on the form including your personal information, referral information, and any supporting documentation.
03
Review the completed form for accuracy and completeness.
04
Submit the form according to the instructions provided.
Who needs chip ph-95 referral cover?
01
Anyone who is referred for CHIP (Children's Health Insurance Program) benefits and is required to submit a referral cover as documentation.
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What is chip ph-95 referral cover?
The chip ph-95 referral cover is a document that provides information about a referral for CHIP (Children's Health Insurance Program) services.
Who is required to file chip ph-95 referral cover?
Healthcare providers and facilities that are referring a child for CHIP services are required to file the chip ph-95 referral cover.
How to fill out chip ph-95 referral cover?
The chip ph-95 referral cover can be filled out electronically or manually by providing the necessary information about the referral, such as the child's details, reason for referral, and healthcare provider information.
What is the purpose of chip ph-95 referral cover?
The purpose of chip ph-95 referral cover is to ensure that the child receives the necessary CHIP services and that the referral process is properly documented.
What information must be reported on chip ph-95 referral cover?
The chip ph-95 referral cover must include information such as the child's name, date of birth, reason for referral, referring healthcare provider's information, and any relevant medical history.
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