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  • Chdp Supplemental Application Form

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1. Legal Name (as listed with Medi-Cal) 2. NPI Provider Number (as related to with site listed on SECTION I # 3) 3. Business Address (number, street) City 4. Business Telephone Number ( ) Email Fax Number ( ) 5. Name of Contact Person 6. Phone # of Contact Person ( ) 7. Provider Type Solo Practice Group Practice Government Clinic (please specify type: ) SECTION II. Zip Code Teaching Institution Other (please specify: ) CHANGE ACTION REQUESTED Pay.

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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!

Who is eligible for a CHDP exam? Children and youth enrolled in Medi-Cal are eligible for periodic CHDP (well-child) exams up to their 21st birthday. Children and youth determined through the CHDP Gateway to be income-eligible can have CHDP exams until their 19th birthday.

​The C​hild Health and Disability Prevention (CHDP) is a preventive program that delivers periodic health assessments and services to low income children and youth in California.

​​​​​​​​​​​​​​​Child Health and Disability Prevention Program. ​The C​hild Health and Disability Prevention (CHDP) is a preventive program that delivers periodic health assessments and services to low income children and youth in California.

To receive CHDP services, children and youth must live in California and meet one of the following requirements: Up to 21 years of age and on Medi-Cal. Up to 19 years of age and from a low-income family. Between the ages of 3 and 5 years and attend a Head Start or state preschool.

Child Health and Disability Prevention Program Forms.

The CHDP Gateway , serves as the entry point for these children to enroll in ongoing health care coverage through Medi-Cal. The CHDP Gateway is based on federal law found in Titles XIX and XXI of the Social Security Act that allows states to establish presumptive eligibility programs for children/youth.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
Bug Bounty Program
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232