Application

Instructions for Membership Application

1. Thoroughly review the  CCPA Bylaws,  CCPA Physician Master Agreement and the  CCPA Product Description. These documents outline the terms and conditions between CCPA and the physician, as well as for participation in CCPA's fee-for-service agreements.
2. If you find the terms and conditions in the above documents agreeable, please use this Application Checklist to complete the CCPA Membership Application.

Please ensure that you complete ALL of the documents below:

• CCPA Attestation and Consent For Release of Information
• Acknowledgement of Confidentiality
• Illinois Credentialing and Data Gathering Form
• CCPA Forms 
• Physician Master Agreement Execution Page

3.  If your practice is new to CCPA, please also complete the following documents:

• W-9
• Practice Billing Information 
• Business Associate Agreement

4.  Submit your completed application materials to CCPA:

Phone: 312.227.7440

Fax: 312.227.9526

Email:  ccpa@luriechildrens.org

Mailing address: 225 E. Chicago Avenue, Box 113, Chicago, IL 60611

Questions about the CCPA membership application?

Please contact Micaela Andres at 312.227.7567 or mandres@luriechildrens.org.