Provider Information Verification Form

Thank you for taking the time to update your information with The CHP Group. We will be using the information you provide today to prepare for our new Provider Portal, as well as develop ways to assist members in seeking culturally appropriate care. If you have questions about the information we are collecting or how it will be used, please contact us at ps@chpgroup.com or call us at 800-449-9479. Thank you.

Provider Name*

Enter the provider's full name.

First Middle Last

Discipline(s)*

Select the provider's discipline(s). Select all that apply.

Acupuncture
Chiropractic
Massage Therapy
Naturopathic Medicine

NPI Type 1 Number*

Enter the provider's NPI Type 1 number.

Unique Provider E-mail Address*

Enter the provider's unique e-mail address. This e-mail address must be unique to the provider. It cannot be a shared e-mail address.

Enter Email Confirm Email

Practice Information

Does the provider practice at more than one location?*

Yes
No

How many locations does the provider practice at?*

Telehealth Services*

Does the provider offer telehealth services?

Yes
No

Telehealth Services - Multiple Locations*

Does the provider offer telehealth services at each location?

Yes
No

If no, please indicate the locations that the provider offer telehealth services from:*

Patient Age Restrictions*

Does the provider have patient age restrictions?

Pediatric only (0-18)
Adult only (19+)
No age restrictions

Patient Gender Restrictions*

Does the provider have any patient gender restrictions (i.e., only treats a specific gender)?

Female
Male
No restrictions

Interpreter Services*

Does your office have interpreter services available?

Yes
No

Interpreter Services - Multiple Locations*

Does the provider offer interpreter services at each location?

Yes
No

If no, please indicate the locations that the provider offers interpreter services:*

Culturally Appropriate Care

CHP is committed to ensuring members have access to culturally appropriate care wherever possible. We are collecting and updating information about our network providers in order to assist members in making care choices that are the most appropriate for their needs.

Race/Cultural Ethnicity*

Please select the provider's race/cultural ethnicity. (Categories below are from the 2020 US Census.)

Provider Information Verification

Practice Information

Culturally Appropriate Care

The CHP Group

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