CHCPCA Application for Non-COPIC Insureds

On April 14, 2004, Colorado Governor Bill Owens signed into law House Bill 04-1354, known as the Health Care Credentials Uniform Application Act. The purpose of the Act is "...to make credentialing more efficient, less costly, and less duplicative by making it uniform through the use of a single application form for the collection of core credentials data...". The Colorado Health Care Professional Credentials Application form became effective for INITIAL credentialing in COLORADO January 1, 2006. Effective May 1, 2006, the Colorado Department of Public Health and Environment announced that the same form shall be effective for RECREDENTIALING in COLORADO as well.

COLORADO PHYSICIANS WHO ARE NOT COPIC-INSURED

Physicians NOT insured or seeking to be insured by COPIC and other interested parties may obtain the Colorado Health Care Professional Credentials Application (CHCPCA) using one of these links:

Microsoft Word format* -- Using Word 2002 or later, open the form, save it to your system, type in your answers, and save to your system for future printing/updating.
PDF format (1.2 MB file)* -- Using a full (i.e., purchased) installation of Adobe Acrobat Standard, open the form, use "SAVE AS" to save to your system, type in your answers, and save the completed copy to your system for future printing and/or updating. Using the free Adobe Reader, open the form, type in your answers, and print a completed copy. You will not be able to save a completed copy to your system, and your answers will be erased when you close the file.

* This version was amended March 21, 2007; it becomes effective July 1, 2007.

COPIC is unable to provide technical support for your download/use of the form. If you experience problems in these areas, please contact your credentialing entity.

Questions regarding the content of the single application form should be directed to Gloria Franczek, Director of Customer Service, at (720) 858-6223 or gfranczek@copic.com.