Form Dhcs 9052 - Genetically Handicapped Persons Program (Ghpp) New Referral Form
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1State of California—Health and Human Services Agency
Department of Health Care Services
Genetically Handicapped Persons Program
GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP) NEW REFERRAL FORM
DATE:
CLIENT INFORMATION
NAME:
DOB:
SEX: M
F
GHPP ELIGIBLE CONDITION:
RESIDENTIAL ADDRESS:
SSN:
(OPTIONAL)
MED-CAL #:
MEDI-CARE #:
MAILING ADDRESS:
OTHER HEALTH COVERAGE:
(MEDICAL)
PHONE #:
(VISION)
MOTHER’S FIRST AND MAIDEN NAME:
(DENTAL)
BIRTHPLACE: (CITY, COUNTY, STATE/COUNTRY)
REFERRING PERSON/AGENCY:
TELEPHONE NUMBER:
FAX:
FOR CALIFORNIA CHILDREN SERVICES (CCS) USE ONLY
COUNTY:
CHILD’S CCS NUMBER:
CONTACT PERSON:
CHILD’S SPECIAL CARE CENTER:
PHONE NUMBER:
FAX NUMBER:
ATTACHMENTS (PLEASE CHECK)
MOST RECENT SCC ANNUAL REPORTS
DNA TEST RESULT OR OTHER TEST CONFIRMING GHPP ELIGIBLE CONDITION
INFORMATION ABOUT UPCOMING SURGERIES/TRANSPLANTS
PLEASE FAX TO THE GHPP AT 916-327-1112
The information requested on this form is required by the Department of Health Care Services, Children’s Medical
Services Branch, GHPP Unit for purposes of identification and enrollment processing. Failure to provide the requested
information may result in delay of GHPP enrollment.
DHCS 9052 (8/07)
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