We created this page to make it easier for CHPW Apple Health (Medicaid) members to find the materials they need. Bookmark this page for quick access to commonly used forms and tools, all in one spot.
Forms & Tools
- Appeals Request Coversheet
To submit an appeal for a denied service or payment (in addition to supporting documentation).
- Health Assessment Survey – Link coming soon
Tell us more about yourself and your health needs, so we can help you develop personalized care plans that help you feel your best.
- Language Assistance “I speak” Cards
Printable cards to help individuals request interpretation. Available in Arabic, Cantonese, Mandarin, Russian, Somali, Spanish, and Vietnamese.
- Pregnancy Notification Form
To let us know you are expecting to give birth, and to sign up for our Healthy You, Healthy Baby program.
- Prior Authorization Lookup Tool
This tool can help you determine if the procedure you need requires prior approval by CHPW
- Privacy/Security Incident Report
To report an event that you believe would be considered a breach of privacy or security.
- Vision Reimbursement Form
To request reimbursement for VSP out-of-pocket costs associated with Apple Health (Medicaid) coverage for an adult age 21 or older.
Protected Health Information (PHI) Forms
- Authorization to Disclose Protected Health Information (PHI)
To allow someone you know to talk to CHPW on your behalf.
- Authorization to Release Substance Use Disorder (SUD) Information
To allow the plan to share information about SUD with your doctor and to pay claims.
- Request for an Accounting of Disclosures of Your PHI
To ask CHPW for all the times your PHI was disclosed to someone other than you.
- Request to Access Your PHI
To see your PHI history with CHPW.
- Request to Correct Your PHI
To correct something in your official health record with CHPW.
- Request to Restrict Disclosures of Your PHI
To ask CHPW not to share your information with others.
How to Submit
Please follow the instructions noted on the form you are using, and submit via:
|Email: save the document to your device, fill out according to directions, and email to [email protected] or the address listed on the form.|
|Mail: print the document, fill out according to directions, sign the form, and mail to: CHPW, ATTN: Customer Service, 1111 3rd Ave, Suite 400, Seattle, WA 98101.|
For More Information
If you have questions, can’t find what you need, or need a hard copy of materials mailed to you, please contact Customer Service: 1-800-440-1561 (TTY: 711), Monday through Friday, 8:00 a.m. to 5:00 p.m.
You may also wish to explore these additional resources: