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County Indigent Health Care Program Handbook
CIHCP Forms
CIHCP Forms
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ES
= Spanish version available.
Title
Form 3064, Application for Health Care Assistance
ES
Form 3065, Worksheet
Form 3066, Report of Changes
Form 3067, Appointment Notice
ES
Form 3068, Request for Information
ES
Form 3069, Health Care Services Record
Form 3072, Monthly Financial Report
Form 3073, Eligibility Dispute Resolution Request
Form 3076, Case Record Information Release
ES
Form 3077, Notice of Eligibility
ES
Form 3078, Claim Processing Notification
Form 3079, Facility Payment Rate Request
Form 3080, SSI Appellant Notification
Form 3081, Appellant – Provider Assignment
ES
Form 3082, Notice of Ineligibility
ES
Form 3083, Optional Health Care Services Notification
Form 3084, Employment Verification
ES
Form 3085, Statement of Self-Employment Income
ES
Form 3086, End of Year Report
Form 3087, TMHP Confidentiality Agreement
Form 3088, Request for State Assistance Funds (90 Percent)
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