Ca Chdp Program Health Assessment Provider Application Page 4
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47.
Pay-to name means the name of the person or business to which payment should be issued by the CHDP Program for CHDP
services provided by the eligible clinicians employed by the CHDP Provider. The pay-to name may be the legal name indicated in
number 1, or another person or business chosen by the Provider Applicant. NOTE: See number 10.
8.
Provide the social security number of the Provider Applicant named in number 1. The social security number is not required if the
Provider Applicant is using their Federal Employer Identification Number (FEIN) requested in number 9.
Attach a clearly legible
copy of the social security card if this number is being provided.
9.
Enter the Federal Employer Identification Number (FEIN) issued by the IRS under the legal name of the Provider Applicant. Attach a
legible copy of IRS Form 941, Form 8109-C, Form 147-C, Form SS-4 (Confirmation Notification), or Form 2363. If the business is a
Sole Proprietorship not using a FEIN, provide the social security number or Individual Taxpayer Identification Number (ITIN) of the
Sole Proprietor. Attach a legible copy of the ITIN, if applicable.
10.
The pay-to address means the location to which payment should be sent. Include the post office box number, street number and
name, room or suite number or letter, city, state, and 5-digit ZIP code.
11.
Indicate the type of business that applies to your business structure. Provide the names of the principal owners.
12.
Provide all active Medi-Cal provider numbers for the address in number 3. If applicable, include the name, address, and Medi-Cal
provider number of each satellite center on a separate sheet and submit with this form. Enter “New Applicant with L&C” if the
Provider Type is a clinic not yet licensed.
13.
Provide the Vaccines for Children (VFC) provider number.
14.
Identify all health care plans in which the Provider Applicant is an active provider, e.g., Medi-Cal Managed Care health plan, Healthy
Families Program, or other children’s health insurance programs.
15.
Indicate your history of providing CHDP services in California and other states by providing the name of the county(ies) and other
state(s), if you are a current or former provider, and from/to dates.
16.
Check the appropriate box to indicate whether your business address has a CLIA waiver or certificate. Provide the certificate
number if the business address has a CLIA certificate and the expiration date of the CLIA waiver or certificate. Attach a legible copy
of the waiver or certificate.
17.
Provide the names, titles, professional license numbers, specialty, and location and length of time clinicians at the business address
provided on this application delivered CHDP services to children and youth up to age 21 years. Attach a copy of each clinician’s
professional license and curriculum vitae.
18.
Describe how your practice provides 24-hour on-call services to the clients seen at the business address on this application. Include
the names of the clinicians providing these services.
19.
Describe how you arrange for hospitalizations of clients needing admission and the names of those hospitals.
20.
If you are applying to be a Health Assessment Only Provider, describe your procedures for referral for diagnosis and treatment and
follow-up of conditions identified during the health assessment.
21.
Name the physician responsible for oversight of the quality of clinical practice at the business address.
22.
Provide the telephone number for the person named in number 21.
23.
Provide the e-mail address for the person named in number 21.
24.
Print the first name, middle initial, last name, and title of the Provider Applicant indicated in number 1.
25.
Provider Applicant signature means the first name, middle initial, and last name of the Provider Applicant indicated in number 1. An
original signature IN BLUE INK ONLY is required. Indicate the date this application is signed. NOTE: Provider Applicant signature
on the CHDP Health Assessment Provider Program Agreement (DHS 4491) means the name and title of the Provider Applicant
indicated in number 1 of the CHDP Health Assessment Provider Application (DHS 4490). An original signature is required. Indicate
the date the program agreement is signed.
Did you remember to enclose (as applicable):
The original, signed CHDP Health Assessment Program Provider Agreement (DHS 4491)
Copy of FEIN or ITIN verification, or social security card, if applicable
Copy of Fictitious Business Name Statement/Permit, if applicable
Copy of CLIA waiver or certificate
Copy of professional licenses, relevant certifications, and curriculum vitae for all clinicians providing CHDP services
Description of 24-hour coverage arrangements
Description of arrangements for hospitalizations, if applicable
Description of referral procedures for diagnosis and treatment, if applicable
Other, if applicable
Send completed form to your local CHDP Program. If not indicated on page 1 of this application, mailing addresses may be found at
Page 4 of 4
DHS 4490 (10/05)
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