Get Chdp Supplemental Application Form
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How to fill out the Chdp Supplemental Application Form online
Completing the Chdp Supplemental Application Form online can streamline your submission process and ensure your information is accurately recorded. This guide will provide you with step-by-step instructions to help you navigate through the form with ease.
Follow the steps to complete the form accurately and efficiently.
- Press the ‘Get Form’ button to access the Chdp Supplemental Application Form and open it in your preferred editing tool.
- Begin with Section I, where you need to provide general information. Fill in your legal name as it appears on Medi-Cal, your NPI provider number, and your business address including city and zip code. Make sure to also include your business telephone number, email, and fax number.
- Continue in Section I by entering the name and phone number of the contact person at your practice. Also specify your provider type, selecting from options such as solo practice, group practice, government, or clinic.
- Move to Section II, which requires you to specify the change action requested. Choose from options such as adding or deleting clinicians, disenrollment, or providing new information. Make sure to include the corresponding details for your selected option.
- In Section III, complete any relevant boxes specific to your requested action. This may include providing your updated NPI provider number, tax ID/SSN, telephone and fax numbers, email, and legal name as listed with Medi-Cal.
- If applicable, fill in details regarding any rendering clinicians being added or deleted. Provide their names, professional license numbers, effective dates, and reasons for the changes. Ensure that any additional documentation required is attached.
- Utilize Section IV for any additional comments that may be necessary for your application. Be succinct but clear in conveying important information.
- After all sections are completed, review your form to ensure that all information is accurate and legible. Make any necessary corrections following the guidelines provided.
- Finally, save your changes, and proceed to download, print, or share the completed form as needed for your records or submission.
Get started on your application and complete the Chdp Supplemental Application Form online today.
The CHDP Program provides FREE comprehensive well-child medical and dental health check-ups for babies, children, and youth under age 21 with Full Scope Medi-Cal or under age 19 with low family income. Who is Eligible? Babies, children, and youth under the age of 19 with low family income. No documentation required!
Fill Chdp Supplemental Application Form
CHDP Pre-Enrollment Application (Vietnamese) pdf icon. CHDP Supplemental Application pdf icon. CHDP Supplemental Application. Send completed form to your local CHDP Program. As of July 1, 2024, The Child Health and Disability Prevention program has ended. The following services will continue under other Medi-Cal delivery systems. Within the "Supplemental Materials" link, providers can locate CHDP-program related forms and helpful links, including but not limited to the following. Links. How do I enroll my child in CHDP? Applications for CHDP services are available at enrolled CHDP provider offices. Hours. CHDP Order Request Form – Complete this form to order PM 160 Billing Reports.
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