Ca Chdp Program Health Assessment Provider Application Page 3
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4INSTRUCTIONS FOR COMPLETION OF THE
CHDP HEALTH ASSESSMENT PROVIDER APPLICATION
For assistance in completing this application, please call your local CHDP Program.
Phone numbers can be found at
Health care providers wishing to enroll as a provider with the CHDP Program must complete an application and be approved by the local
CHDP Program in order to bill the CHDP Program for CHDP services. Laboratories must use the CHDP Laboratory Provider Application
(DHS 4502).
Omission of any information or documentation on this application or the failure to sign this application may result in delays in processing or
inability to process this application. Provider Applicants may be contacted orally or in writing if additional information and documentation
are needed. A separate application must be completed if you wish to apply for participation in the CHDP Program in more than one
location. Upon review and approval of the complete application and an on-site facility and medical record review, the Provider Applicant
will be assigned a provider number to use when billing the CHDP program.
Who can apply: Pediatricians, Family Practitioners, and Internists (for youth 14 years of age and older) or Independent Certified Family or
Pediatric Nurse Practitioners, and clinics/agencies employing the preceding types of professionals, may be considered for status as a
Comprehensive Care or Health Assessment Only Provider.
Application for participation as:
A Comprehensive Care Provider means that the Provider:
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Provides all preventive health assessment services as outlined in the CHDP Program Health Assessment Guidelines;
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Is responsible for the overall follow-up and medical case management for a child initially evaluated through the CHDP Program by
initiating diagnosis, treatment, and follow-up for discovered or suspected conditions identified during the health assessment and
referring to specialty care when appropriate;
Provides families and/or patient with written summary of findings;
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Is available as the source for primary medical care, serving as a medical home, on an ongoing basis for medical services;
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Assures the availability of medical services after usual and customary office hours;
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Maintains records for each child receiving a CHDP health assessment.
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A Health Assessment Only Provider means that the Provider:
Provides all preventive health assessment services as outlined in the CHDP Program Health Assessment Guidelines;
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Documents in the child’s record the referral for all children with discovered or suspected conditions identified during the health
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assessment needing definitive diagnosis, treatment, and follow-up services;
Provides families and/or patient with written summary of findings;
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Provides referral/follow-up report form to families and/or patient to be given to the provider(s) to whom the child has been referred for
follow-up care showing the reason for referral;
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Maintains records for each child receiving a CHDP health assessment.
Different fee schedules have been established for Comprehensive Care Providers because of their ability to provide ongoing coordinated
care to CHDP-eligible children as described above.
Provider type: Each provider type must meet specific license and registration requirements. Check the appropriate box that describes
your profession or business for which you are applying to obtain a CHDP provider number in order to bill the CHDP Program. Check the
“clinic” box if your type is a Hospital Outpatient Clinic, Rural Health Clinic, Community Health Clinic, Indian Health Clinic, etc., and specify
what type of clinic. Identify the type of practice if the selection is “Other,” such as schools. Call the office listed above if assistance is
needed in determining your provider type. A separate application must be completed if you wish to apply for participation in the CHDP
Program in more than one location.
1.
Legal name of Provider Applicant means the name under which the Provider Applicant is applying for a CHDP provider number in
the CHDP Program and listed with the Internal Revenue Service (IRS).
2.
Business name means the name of the Provider Applicant if different from that listed in number 1. If this is a fictitious business
name, provide the Fictitious Business Name Statement/Permit number and effective date.
Attach a legible copy of the
record/stamped Fictitious Business Name Statement/Permit to the application.
3.
Business address (office/site of practice) means the office or location where the Provider Applicant is providing services, including
the street name and number, room or suite number or letter, city, county, state, and 5-digit ZIP code. A post office box or
commercial box is not acceptable.
NOTE: Provider Applicants with multiple business addresses where CHDP services will be
provided must complete a separate application for each business address.
4.
Business telephone number means the primary business telephone number used at the Provider Applicant’s business address. A
beeper number, answering service, answering machine, pager, facsimile machine, or cellular phone is not acceptable as the
business telephone number.
5.
Fax number means the facsimile number used at the business address in number 3 on this application.
6.
E-mail address means the address to which electronic communications may be sent.
Page 3 of 4
DHS 4490 (10/05)
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