Do it all here. From paying your bills to submitting an appeal, find commonly requested tools and forms on this page.
Bookmark this page for quick access to commonly used forms and tools, all in one spot.
Tools
Treatment Cost Calculator (TCC)
Use this tool to not only get an estimate on services, but find facilities that offer the care you need and leave reviews on providers you have interacted with.
Prior Authorization Lookup Tool
This tool can help you determine if the procedure you need requires prior approval by CHPW.
Pay your bills
Pay your monthly premium or health care bill online using our secure portal, E-Bill Express, or request another payment option.
Searchable formularies
Formularies are lists of covered prescriptions. Choose the right formulary for your Medicare Advantage plan, and then search for your medication by name or by what condition it treats.
Forms and documents
Plan documents
Get your Evidence of Coverage (EOC) document, Plan Change form and more plan documents.
Appeals Request Coversheet
To submit an appeal for a denied service or payment (in addition to supporting documentation). To learn more, and to access informative guides, instructions and examples, please visit our Appeals and Grievances page.
Health Assessment survey
Tell us more about yourself and your health needs, so we can help you develop personalized care plans that help you feel your best.
Prescription coverage determination request form
If you are taking a medication that is not in our formulary, you can ask us to make an exception. You can also ask us to waive restrictions or limitations on your drug. For example, quantity limits or step therapy restrictions. You can also file this request online.
Physician Orders for Life Sustaining Treatment (POLST) Form
This form is for anybody who has a serious health condition, and needs to make decisions about life-sustaining treatment. Your provider can use the POLST form to represent your wishes as clear and specific medical orders. See the advance directives and POLST policy for more information.
Privacy/Security incident report
To report an event that you believe would be considered a breach of privacy or security.
Protected Health Information (PHI) forms
Use the following forms to update your information and authorize who can access your Protected Health Information. For more information, please visit our Member Rights page.
Authorization to disclose Protected Health Information (PHI) (Spanish)
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:
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Email: save the document to your device, fill out according to directions, and email to [email protected] or the address listed on the form. |
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Mail: print the document, fill out according to directions, sign the form, and mail to:
Community Health Plan of Washington |
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: 1-800-942-0247 (TTY: 711), Monday through Friday, 8:00 a.m. to 8:00 p.m.
Did you know that certain prescription medicines are available as a 90-day supply? Medicine that you take on a long-term basis to manage your health is called a “maintenance drug.” A 90-day supply makes it easier to keep taking the medicine you need to feel your best. You may also be eligible to receive your long-term medications through free home delivery.
