Ca Chdp Program Health Assessment Provider Application
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4State of California—Health and Human Services Agency
Department of Health Services
Children’s Medical Services Branch
California Child Health and Disability Prevention (CHDP) Program
CHDP HEALTH ASSESSMENT PROVIDER APPLICATION
IMPORTANT:
For Local CHDP Program Use Only
Refer to attached instructions to complete this form.
CHDP Program
3
Type or print legibly.
3
Laboratories please use the CHDP Laboratory Provider Application
Address (number, street)
3
(DHS 4502).
Return completed form and required attachments to your local
3
City
County
State ZIP code
CHDP Program. Addresses may be found at
CA
Application for participation as (check one):
Provider type (check one):
Solo practice
Government
(Please see instructions for description.)
Comprehensive Care Provider
Group practice
Teaching institution
Health Assessment Only Provider
Clinic (please specify type)
Other (please specify)
1. Legal name of Provider Applicant as listed with the IRS
2. Business name if different from legal name
Is this a fictitious business name?
If yes, list the Fictitious Business Name Statement/Permit number
Effective date
Yes
No
(Attach a legible copy of the Fictitious Business Name Statement/Permit.)
3. Business address (office/site of practice)
Number, street
City
County
State
ZIP code
4. Business telephone number
5. Fax number
6. E-mail address
(
)
(
)
8. Social security number (SSN)
9. Federal Employer ID Number (FEIN)
7. Pay-to name (last)
(first)
(middle initial)
(Required if not using a FEIN) (attach
(attach a copy)
a copy)
10. Pay-to address
Number, street
City
State
ZIP code
11. Type of business (check one):
Sole proprietor
Corporation
Partnership
Limited liability corporation
Other
(please specify)
Principal owners
12. Active Medi-Cal provider number(s) for business address
14. Active provider in (check all that apply)
listed in number 3 (see instructions)
Medi-Cal Managed Care plans (please specify)
Healthy Families plan (please specify)
13. Vaccines for Children (VFC) provider number
California Children’s Services
Other children’s health insurance program (please specify)
15. History of providing CHDP services (attach additional sheets if needed)
Current Provider
Former Provider
Name
Yes
No
Yes
No
(If yes, specify from/to dates)
California County(ies)
From _________
To ________
Other State(s)
From _________
To ________
For LOCAL CHDP PROGRAM Use Only
Date CHDP Provider Data
Reviewed by CHDP Director (print name)
Signature
Date signed
Sheet (PM 177) sent to State
Page 1 of 4
DHS 4490 (10/05)
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Parent category: Medical