Child Health & Disability Prevention (CHDP) Program

Department of Health Services - Children's Medical Services Branch

State of California - Health and Human Services Agency

Instruction 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 this patient less than 19 years of age?

Yes No

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 Health Families.

I want to apply for continuing coverage through Medi-Cal or Health Families

Yes No

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 the 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 No

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

Patient Name:

First Name:

Middle Initial:

Date of Birth:

Gender:

Male Female

Patient's Social Security number (SSN) (Optional)

If you are homeless, check here. Enter the general location in the "Home Address" section and complete the "Mailing Address" section.

Home Address:

Apartment #:

City:

State:

Country of Residence:

Zip Code:

Mailing Address:

if different from home address

Apartment #:

City:

State:

Zip Code:

Mother's Name:

First Name:

Middle Initial:

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

If less than one year of age, did the infant live with the mother in the month of birth?

Yes No

Mother's Date of Birth:

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.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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 for keeping the information is the Department of Health 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.

Your information will be encrypted.