Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency Page 3
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
1
2
3
4
5
6
7
8
9
10State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
20. Do You Have: a. Dental Insurance?
Yes
No
If Yes, Name of Plan:_______________________________
b. Vision Insurance?
Yes
No
If Yes, Name of Plan:____________________________________
Section C: Certification
(Initial and Sign Below. Your Signature Authorizes the GHPP to Proceed with Your Application.)
Read and Initial Each Statement Below:
_____ I am applying to the GHPP in order to determine my eligibility for services/benefits. I understand that the completion of
this application does not guarantee my acceptance into the GHPP.
_____ I give my permission for the GHPP to verify my residence, health information, income and/or other circumstances which
may be required to determine my GHPP eligibility and enrollment fee amount (if any).
_____ I give permission for the GHPP to leave messages concerning my GHPP participation on my designated telephone
answering machine/service.
_____ I certify that I have read this information, or had it read to me, and that I understand it.
_____ I certify that the information I have given on this form is true and correct to the best of my knowledge.
Signature of GHPP Applicant or Parent/Legal Guardian of Minor Child:
Relationship to Minor Child:
Date:
If Signing with an “X”, Signature of
Relationship of Witness to GHPP
Witness Phone
Date:
Witness:
Applicant:
Number:
_____________________________
_______________________________
________
California law requires that families applying for services be given information on how GHPP protects their privacy.¹
To protect your privacy:
GHPP must keep this information confidential.²
GHPP may share information on the form with authorized staff from other health and welfare programs only when you
have signed a consent form.
You have the right to see your application and GHPP records concerning you. If you wish to see these records contact the
GHPP at 1 (916) 327-0470 or toll free at 1 (800) 639-0597. By law, the information you give GHPP is kept by the program.³
1 Civil Code, Section 1798.17
2 In accordance with Section 41670, Title 22, California Code of Regulations and the California Public Records Act (Government Code, Sections
6250-6255)
3 Section 123800 et. seq. of the California Health and Safety Code
DHCS 4000 A (10/10)
Page 3 of 6
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 5080 - California C-9 Personal Rights Substance Use Disorder Treatment Facilities - Health And Human Services Agency
Legal
Form Dhcs 4480 - California Application To Determine Ccs Program Eligibility - Health And Human Services Agency
Legal
Form Dhcs 7077 - California Notice Regarding Standards For Medical Eligibility - Health And Human Services Agency
Legal
Dhcs 4073 - California Child Health And Disability Prevention (chdp) Program Pre-enrollment Application (russian) - Health And Human Services Agency
Legal
Dhcs 4073 - California Child Health And Disability Prevention (chdp) Program Pre-enrollment Application (hmong) - Health And Human Services Agency
Legal
Dhcs 4073 - California Child Health And Disability Prevention (chdp) Program Pre-enrollment Application (chinese) - Health And Human Services Agency
Legal
Dhcs 4073 - California Child Health And Disability Prevention (chdp) Program Pre-enrollment Application (armenian) - Health And Human Services Agency
Legal
Form Dhcs 4098 - California Children's Services Medical Therapy Program (mtp) Therapy Assessment Plan - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal