Child Health & Disability Prevention (CHDP) Program

Pre-enrollment Application Form

Please correct the errors described below.

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

How much money does your family make before taxes?

You or your child may be eligible for continued health care coverage through Medi-Cal or Health Families.

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

if different from home address

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

Parent/Legal Guardian Information



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.

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.