Get Well Child / Program Form - Community Health Plan Of Washington
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How to fill out the Well Child / Program Form - Community Health Plan Of Washington online
This guide provides clear and detailed instructions on how to complete the Well Child / Program Form from the Community Health Plan of Washington. Whether you're familiar with online forms or new to the process, our step-by-step approach will ensure you complete the form accurately and efficiently.
Follow the steps to fill out your Well Child / Program Form seamlessly.
- Click ‘Get Form’ button to access the Well Child / Program Form and open it for completion.
- Fill in the Member Name (Child) field with the child's full name as registered with the Community Health Plan of Washington.
- Enter the CHPW ID Number for the child, which can be found on the member ID card.
- Provide the Child’s Date of Birth using the format Month/Day/Year.
- Input the Parent/Guardian Name by clearly printing their full name in the designated area.
- Sign the form in the Parent/Guardian Signature section to authorize the submission of the information.
- Complete the Mailing Address section with the current residential address, ensuring accuracy.
- Fill in the City, State, and Zip code in the respective fields below the mailing address.
- Provide a contact Phone Number where you can be reached for any follow-up regarding the form.
- The facility staff will need to complete their section, confirming immunization status and signature.
- Review the entire form for accuracy and completeness before submission.
- Once completed, save the form changes, and you may choose to download, print, or share the form as needed.
Complete your Well Child / Program Form online today to ensure your child's eligibility for rewards.
Yes, the Community Health Plan of Washington operates under the Medicaid program, specifically for residents using Apple Health. This plan provides necessary health services to eligible individuals and families. If you are completing the Well Child / Program Form - Community Health Plan Of Washington, you’ll find that this plan is aligned with Medicaid to support your healthcare journey.
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