Forms Center
Check here for important information and forms to help direct your care as a CHP member.
If you are a Medicare member, click here for Medicare forms.
- Tips for Better Laboratory Services Brochure (pdf 1.01 MB)
- Performance Drug List
- Immunization Chart for Children (pdf 398.81 kB)
- Immunization Chart for Adults (pdf 155.41 kB)
Fitness Center Reimbursement
(For more information on the reimbursement program or to see a list of facilities offering discounts to CHP members, check our Health & Fitness Section)
- Fitness Center Reimbursement (pdf 254.88 kB)
Protecting your privacy:
- Notice of Privacy Practices (pdf 45.90 kB)
- Communication Directive (pdf 29.34 kB)
- Authorization to Disclose Protected Health Information (msword 73.50 kB)
Assign someone to represent you in accordance with HIPAA regulations:
- Appointed Representative form (pdf 11.11 kB)
Provide verification of eligibility for dependents who attain or exceed age 19. For more information on dependent eligibility determination, click here (pdf 30.38 kB) .
- Dependent Eligiblity Verification Form (pdf 37.25 kB)
Important: These forms are for Capital Health Plan members and enrolled employer groups only. Electronic submission will not be accepted. Members must submit signed forms to their Personnel Office for processing:
- Enrollment form (pdf 53.85 kB)
- Member Status Change Request (pdf 204.42 kB)
