Forms & Documents
Filling out forms and applications can be tedious. We can ensure that the process is smooth and is completed in a timely manner. Prior to completing and submitting any documents, please contact us at 203.949.4194 to ensure the submission of accurate and complete information.
PCMH Readiness Evaluation Questionnaire
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the Readiness Evaluation Questionnaire below
- IT IS IMPORTANT TO FOLLOW THESE INSTRUCTIONS AFTER CONTACTING THE PCMH PROGRAM ADMINISTRATOR:
- Right click the link below and choose “Save Target as...” to download the file to your desktop
- Open the pdf from the desktop in Acrobat Reader and fill it out
- Once it is completed, save the file and click the submit button
- Download the PCMH Readiness Evaluation Questionnaire
PCMH Readiness Evaluation Questionnaire for Level 2 or Level 3 NCQA recognized practices
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the Readiness Evaluation Questionnaire below
- IT IS IMPORTANT TO FOLLOW THESE INSTRUCTIONS:
- Right click the link below and choose “Save Target as...” to download the file to your desktop
- Open the pdf from the desktop in Acrobat Reader and fill it out
- Once it is completed, save the file and click the submit button
- Download the Readiness Evaluation Questionnaire
Glide Path Application
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the Readiness Evaluation Questionnaire below
- IT IS IMPORTANT TO FOLLOW THESE INSTRUCTIONS:
- Right click the link below and choose “Save Target as...” to download the file to your desktop
- Open the pdf from the desktop in Acrobat Reader and fill it out
- Once it is completed, save the file and click the submit button
- Download the Glide Path Instructions and Application
PCMH Application
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- Once you have contacted us, feel free to download the PCMH Instructions and Application below
- IT IS IMPORTANT TO FOLLOW THESE INSTRUCTIONS:
- Right click the link below and choose “Save Target as...” to download the file to your desktop
- Open the pdf from the desktop in Acrobat Reader and fill it out
- Once it is completed, save the file and click the submit button
- Download the PCMH Instructions and Application
PCMH and Glide Path Change request form
Please be sure to read all instructions prior to completing this form
- Contact the PCMH Program Administrator at 203.949.4194 or via email, pcmhapplication@chnct.org for assistance with this process
- These revisions include:
- Adding or removing a practitioner
- Adding a new practice location address
- Updating an existing PCMH or Glide Path practice address or
- Updating/correcting a provider name
Attention: When adding a provider to your PCMH roster by completing a PCMH/GP Change form, claims previously paid for which enhanced rates are due will require you to complete a claim adjustment for each claim in question via HP’s Secure Web portal. Please note, these claims will be included in a future monthly HP re-processing project and will pay the enhanced rate at that time if you choose not to individually adjust these claims via the Secure Web portal at this time.
