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CHIP Documentation Submission Form

Questions? Call us at 1-800-978-8762 (TTY: 711).

Required fields*

PCP Information

Child 1 Information

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Parent/Guardian’s Information

Upload Documents

Before uploading the documentation, please specify the document type. If you have more than one document, please select all document types that apply.

To select multiple documents at once, hold down the CTRL (Windows) or Command (⌘)(Mac) button while selecting. You can upload a maximum of 10 files per submission. The file size of all uploads per submission must not exceed 40 MB. We accept JPEG, TIFF, PNG, PDF, Word and Excel files. If you have more than 10 files or exceed 40 MB, please complete an additional submission.

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