Documents you may need

In response to the current public health emergency, the Pennsylvania Children’s Health Insurance Program (CHIP) is making temporary changes to its program requirements. These changes are designed to ease access to CHIP and to keep families enrolled in CHIP for the duration of the public health emergency.

Read DHS's COVID-19 CHIP Notice.

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Here you can find electronic copies of many UPMC for Kids resources, including documents, forms, and more. If you would like printed copies instead, please call a Health Care Concierge at 1-800-650-8762 (TTY: 711).

Benefits

Member Handbook
Summary of Benefits Booklet
Exclusions Booklet
Pharmacy Benefits Booklet
Explanation of Benefits Tutorial
Invoice Tutorial

Eligibility

CHIP Document Submission Form
Application Form
Renewal Form
Income Guidelines Chart

Reimbursement Forms

Prescription Drug Claim Form
Out-of-Network Care Claim Form
Flu Shot Reimbursement Form

Member Rights and Privacy

Personal Representative Designation Form
Member Authorization to Use or Disclose Protected Health Information
Privacy Statement
UPMC for Kids Notice of Privacy Practices
Pennsylvania Department of Human Services’ Notice of Privacy Practices

Caring for Kids Newsletter Archive

Issue 2, 2021
Issue 1, 2021
Issue 1, 2020