Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency Page 2
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10State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
Section B: Health Insurance Information
17. Do You Have Medi-Cal?
Yes
No
a. If Yes, What is Your Beneficiary I.D. Card (BIC) Number? ______________________________________________
18. Do You Have Medicare?
Yes
No
a. If Yes, What is Your Medicare Number? __________________________
b. Please Check All Medicare Programs in which You are Enrolled:
Part A
Part B
Part C
Part D
19. Do You Have Other Health Insurance?
Yes
No
a. If Yes, Through your Employer
Through a Family Member
Through retirement Benefits
Name of Insurance Company: _____________________________________________
b. Type of plan: Preferred Provider (PPO)
Health Maintenance Organization (HMO)
Other (Specify)____________
c. Policy Number____________________________________________ Coverage Start Date:_______________________
d. Who Pays for the Policy?
Employer
Self
Employer and Self
State of California HIPR Program
Other (Specify) ______________________________________
e. When cost-effective, the Health Insurance Premium Reimbursement (HIPR) Program may reimburse for the cost of your
third-party health coverage. Are you currently participating in the HIPR Program?
Yes
No
If yes, would you like the State of California HIPR Program to continue reimbursing you?
Yes
No
If no, would you like reimbursement for your third-party health coverage premiums?
Yes
No
f. Has any of your insurance information changed?
Yes
No
If yes, please explain why:
__________________________________________
____________________________________________________
__________________________________________
____________________________________________________
g. If your employer provides health insurance and you choose not to participate in your employer’s plan, state why by choosing
one of the following:
The premium is too expensive.
I lost my job and am eligible to continue my coverage under COBRA and can not afford to pay the insurance premium.
The employer’s health insurance coverage is not available because I have met the lifetime coverage limit.
The physician providing care for my condition is not part of the plan’s provider network.
Other (please specify) ________________________________________________________________________________
h. During the last six months from the date of this application, has either your employer or yourself terminated your employer’s
sponsored health insurance? Yes
No
If yes, what date was it terminated? _______________________ Please state why by choosing one of the following:
Loss of employment or a change in employment status.
Your employer discontinued health benefits to all employees or dependents.
A change of address to a ZIP Code that is not covered by your employer’s health insurance.
Death of or legal separation/divorce of the individual through whom the health insurance was provided.
The employer’s health insurance coverage became unavailable because you have met the lifetime coverage limit.
Coverage was under a COBRA policy and the COBRA coverage period has ended.
Other (please specify) _______________________________________________________________________________
DHCS 4000 A (10/10)
Page 2 of 6
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