Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency Page 6

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State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
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? Check the correct response. If yes, include the date
the insurance was terminated and the reason why it was terminated. If you check “Other” please explain.
20.
Do you have
a.
Dental Insurance? Check the correct response (Yes or No). If Yes, write the name of the plan.
b. Vision insurance? Check correct response (Yes or No). If Yes, write the name of the plan.
Section C: Certification: Read and initial the statements where indicated on the form. Then sign and date in ink, in the spaces
provided. If you sign your name with an “X,” you must have a witness sign in the space indicated.
Submitting your application: Mail the completed form to the GHPP at: Genetically Handicapped Persons Program, MS 8100,
P.O. Box 997413, Sacramento, CA 95899-7413.
DHCS 4000 A (10/10)
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