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- Click ‘Get Form’ to open the ccp form in the editor.
- Begin with Section A: Client Information. Fill in the client's name, Medicaid number, and date of birth accurately to ensure proper identification.
- Move to Section B: Supplier/Vendor/Qualified Rehabilitation Professional (QRP) Information. Enter the supplier's name, contact details, and TPI/NPI numbers as required.
- In Section C, provide a clear diagnosis and explain the medical necessity for the requested services. This section is crucial for approval.
- Proceed to Section D: Dates of Service and HCPCS Code. Specify the service dates, HCPCS code/modifier, and a brief description of requested services along with quantity/frequency.
- Finally, complete Section E by having the primary practitioner certify the information. Ensure their signature, printed name, TPI/NPI numbers, and license number are included.
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