Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency

Download a blank fillable Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP)
APPLICATION TO DETERMINE ELIGIBILITY
Refer to the Instructions on Page 4, 5 and 6 When Filling in this Application
Please provide all the information requested and return this form to the GHPP.
PLEASE TYPE OR PRINT. DO NOT ABBREVIATE.
If you have any questions about completing this form,
call the GHPP at 1 (916) 327-0470 or toll free at 1 (800) 639-0597.
Section A: Personal Information
1. Name (Last)
(First)
(MI)
2. Other Name(s) Used
3. Social Security Number
(Optional)
4. Address (Number, Street, Apartment Number)
City
County
Zip Code
4(a). Mailing Address (if different from above)
City
County
Zip Code
7. Mother’s First and Last (Maiden) Name
5. Day Telephone Number
6. Evening Telephone
8. Primary Language
Number
9. Date of Birth (mm/dd/yyyy)
10. Place of Birth
County:
State:
Country:
11. Gender
Male
Female
12. What is Your GHPP Eligible Condition?
13. Race/Ethnicity
14. Name of Your Physician Who Treats Your GHPP Eligible Condition?
15. Name of your Special Care Center Facility
_____________________________________
14(a). Treating Physician’s Address
______________________________________________________________
______________________________________________________________
14(b). Treating Physician’s Phone Number
(
)
16. Power of Attorney/Conservator Information (If Applicable)
YOU MUST ATTACH SUPPORTING DOCUMENTATION
Name:
Title:
Address:
Telephone Number:
DHCS 4000 A (10/10)
Page 1 of 6

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 10