Permission to Enroll in CHAMPS

Congratulations on your interest in becoming a paid caregiver for your family friend and/or loved one. Please complete this form in it's entirety. Incomplete forms will not be processed.

By completing this form you are agreeing to have the agency provider [Humanistic Home Care] create your MILogin user ID and enroll you in CHAMPS. The agency provider may use your MILogin user ID to check on your CHAMPS enrollment application. The agency provider will give you your MILogin user ID. If your CHAMPS enrollment application is approved, the agency provider will also give you your CHAMPS Provider ID.

Community Health Automated Medicaid Processing System (CHAMPS) Request to Be Enrolled

* Indicates required field

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone Number *

Have you ever been convicted of a felony or misdemeanor crime? *

Yes No

Have you ever been removed from or told you cannot participate in a state or federally funded program? *

Yes No

If yes, please tell us what program and why. *

SS# Required for background check *

Please feel free to share any questions or comments you have below. *

Please note that you will only be paid once Humanistic Care has received the reimbursement funds from the clients insurance. Please check the box to acknowledge that you understand and agree to this condition of payment. *

I agree

Submit

Welcome Future Caregiver!

Congratulations on your interest in becoming a paid caregiver for your family friend and/or loved one. Please complete this form in it's entirety. Incomplete forms will not be processed.

Community Health Automated Medicaid Processing System (CHAMPS) Request to Be Enrolled

We look forward to supporting you!

Hours

Telephone

Address