Form Dhcs 4073 - Child Health And Disability Prevention (Chdp) Program Pre-Enrollment Application

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State of California—Health and Human Services Agency

Department of Health Care Services

Children’s Medical Services Branch

CHILD HEALTH AND DISABILITY PREVENTION (CHDP) PROGRAM

PRE-ENROLLMENT APPLICATION

Instructions to the Parent or Patient:

• In order to receive a health examination today at no charge, you must provide the information required on this form. The

information you give is confidential. This is a voluntary program.

Is the patient less than 19 years of age?

Yes

How many people are in your family?

How much money does your family make before taxes?

Monthly

Yearly

• You or your child may be eligible for continued health care coverage through Medi-Cal or premium assistance programs

under Covered California.

I want to apply for continuing coverage through Medi-Cal or premium assistance programs under

Yes

Covered California.

If you answered yes to this question, an application will be mailed to you in a few days. Please return it promptly. If you

answered no to this question (or if you answered yes but do not return the application), the patient’s coverage for health,

dental, and vision benefits will stop at the end of next month unless the county Department of Social Services notifies you

otherwise.

Patient Information

Does the patient have a State of California Benefits Identification Card (BIC) or Medi-Cal card?

Yes

If yes, what is the identification number on the BIC card (if available)?

P atient’s name—Last

First

Middle initial

Date of birth (month/day/year)

Gender

Patient’s social security number (SSN) (optional)

Male

emale

If you are homeless, check here. Enter the general location in the “Home address” section and complete the “Mailing address” section.

Home address

Apartment number City

State

ZIP code

County of residence

Mailing address (if different from home address)

Apartment number City

State

ZIP code

Mother’s name—Last

First

Middle initial

For patients under one year of age, please complete this section.

Mother’s date of birth (month/day/year)

Mother’s BIC or Medi-Cal card number or social security number

Parent/Legal Guardian Information

Name of parent/legal guardian or emancipated minor patient—Last

First

Middle initial

Home telephone number

Work telephone number

Message telephone number

(

)

(

)

(

)

What language do you speak at home?

What language do you read best?

Certification

I am requesting a CHDP health examination today. I certify that I have read and understand this form. I declare that the

information I have provided is true, correct, and complete.

Signature of parent/guardian or emancipated minor

Relationship to patient

Date

An individual has a right to review records containing his/her personal information. The official entity responsible for keeping the information is the Department

of Health Care Services, MS 8100, P.O. Box 997413, Sacramento, CA 95899-7413. A copy of this information may be shared with the county Department of

Social Services in the county in which you reside and will be kept with your child’s medical record by your child’s CHDP provider.

DHCS 4073 (Rev 10/13)