Resources and Forms

Provider Reference Guide

Provider Reference Guide (revised 3/26)

Tools for Filing Claims

CMS 1500
Claim Adjustment Request
Claim Status Inquiry
Recoupment Inquiry Form
Appeal Request Form

Miscellaneous Forms

Confidential Exchange of Information Form
Provider Participation Application (click here for more information)
Member Eligibility & Benefit Verification Form
LCHP Infant Car Seat Form (English/Spanish)
LCHP Toddler Car Seat Form (English/Spanish)
LCHP Boost Car Seat Form (English/Spanish)
Case Management Referral Form
Baby Love Referral Form

Clinical Resources
Access recommendations of the U.S. Preventive Services Task Force (USPSTF) at the click of a button. This free resource helps clinicians identify the screening, counseling, and preventive services that are appropriate for their patients.

Questions?

We’re here to help!
You can reach us at 505.727.LOVE or toll free at 800.808.7363.
You can send a fax at 505.727.5303

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