Form Dhcs 4000 A - California Genetically Handicapped Persons Program (Ghpp) Application To Determine Eligibility - Health And Human Services Agency Page 8

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State of California – Health and Human Services Agency
California Department of Health Care Services
Genetically Handicapped Persons Program (GHPP)
GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP)
INITIAL/ANNUAL INCOME VERIFICATION
Refer to the Instructions on Page 3 and 4 When Filling in this Application
Section D: Certification
Read and Initial Each Statement Below:
_____ I understand that my enrollment fee, if any, will be based on my stated income and that my enrollment fee may change
annually if my income changes.
______I give my permission for the GHPP to verify my income and/or other circumstances which may be required to determine my
annual enrollment fee, if any.
______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/Client or Parent/Legal Guardian of minor
Relationship to Minor Child:
Date:
child:
____________________________________________
_____________________
____________________
If Signing with an “X,” Signature of
Relationship of Witness to
Witness Telephone Number:
Date:
Witness:
GHPP Applicant/Client:
______________________________
Print name
______________________________
_______________________
______________________
____________________
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
DHCS 4000 B (2/08)
Page 2 of 4

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