CHIP Documentation Submission Form

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

Required fields*

Reason for contacting us*

You have selected other, please explain*

Case Record Number

PCP Information

Name of PCP*

Group Name of PCP*

PCP Address*

City* State*

ZIP Code*

Child 1 Information

Child 1 First Name*

Child 1 Last Name*

Child 1 Date of Birth (mm/dd/yyyy)*

Add Child

Parent/Guardian’s Information

Parent/Guardian’s First Name*

Parent/Guardian’s Last Name*

Phone Number* Phone Type*

Email Address*

Address*

City* State*

ZIP Code*

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.

Documents Attached

Please explain*

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.

Upload Files

Have additional information to share? Please share here.

Submit

UPMC FOR KIDS MEMBERS

UPMC FOR KIDS Prospective Members

By Mail

CHIP Documentation Submission Form

PCP Information

Child 1 Information

Parent/Guardian’s Information

Upload Documents

MyHealth Matters

Download Our Mobile App