Links & Forms

PROVIDER INFORMATION

Physician Application Form

Physician Address and Billing Information Change Form

Physician Status Change Request Form

Physician Resignation Form

UTILIZATION MANAGEMENT INFORMATION

2022 Authorization Request Form

CCHCA Services Requiring Prior Authorization List

Case Management Referral Form

CLAIMS INFORMATION

Provider Disputes

Instructions

Form Download

EFT & ERA FAQ

Authorization for EFT Form

835 ERA Office Ally Enrollment Form

ERA Transfer Request

PROVIDER PORTAL

Provider Portal Login

Provider Portal Request Form

Provider Portal User Guide

Provider Portal Demonstration Video

NATIONAL PROVIDER IDENTIFIER

National Provider Identifier Information Link

FOR PATIENTS

Advance Health Care Directive

Physician Directory

Preferred Outpatient Facilities

Questions or concerns? Please contact Provider Relations at Provider.Relations@cchca.com or call 415-216-0088 ext. 107