CWIP Form Fillable

Please enter your 1193 CWIP Information below and attach your completed form to begin

All fields with " * " are Required Fields

Medicaid Parent Information:

Medicaid Parent Last Name*

Medicaid Parent First Name*

Parent Birthdate*

Parent Phone Number

Parent Email Address

Parent Medicaid ID (NOT Child Medicaid ID)*

Mailing Address*

City*

State*

Zip Code*

Child Information:

Child Last Name*

Child First Name*

Child Birthdate*

Provider/Exam Information:

Exam Date*

Provider Last Name*

Provider First Name*

Provider NPI#*

*Attach Image of Completed DHS 1193 Form (PDF, Image)

NOTICE: ONLY DHS 1193 FORMS WILL BE ACCEPTED.