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Letter of Interest

Community First Health Plans (CFHP) continuously monitors and evaluates the availability and access to care services provided in our network. CFHP's ongoing assessment of its provider network against availability and access standards ensures adequate services throughout the network. If you are interested in joining CFHP, please complete the following information below.


* Fields marked with a red asterisk are required.

General Information:
* First Name:
* Last Name:
* Title:
* Name of Group/Facility:

* Provider Specialty:
	Primary Care Provider
	Specialist
	Behavioral Health
	Ancillary
	Other:

Specialty Details (optional):


* Office Location(s):


* Billing Address(es):


* Federal Tax ID#:
* NPI#:
TPI#:	(Provider accepting Medicaid only)
TH Steps TPI#:	(PCP only)

* Panel Restrictions (If none, enter none):


* Products of Interest:	Medicaid CHIP HMO

Contact Person:
* Name:
* Email:
* Phone:

* Do you submit claims electronically?
Yes No

Please identify your appropriate organization's Federal status, if applicable:
Rural Health Clinic (RHC) Historically Underutilized Business (HUB) (Need # or HUB Certification) Federally Qualified Health Center (FQHC) Significant Traditional Provider (STP)

For DME and Home Health Providers, please define your organization's scope-of-service and the geographic location you intend to provide services. Please submit additional information on a separate sheet of paper if needed.
Upload Letter:

Comments (optional):

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