Get Chdp Health Assessment Provider Application. Dhcs 4490 - Dhcs Ca

Filling out the CHDP Health Assessment Provider Application is a critical step for health care providers wishing to enroll in the California Child Health and Disability Prevention Program. This guide provides step-by-step instructions to assist you in completing the application accurately and efficiently.

Follow the steps to complete your application successfully.

1. Click ‘Get Form’ button to obtain the application form and open it in the designated application interface.
2. Begin by selecting the appropriate box to indicate the type of CHDP Program participation you are applying for. This could include options such as solo practice, group practice, or clinic.
3. Provide your legal name as listed with the IRS in the designated field. If your business name differs, fill it in accordingly.
4. Indicate whether your business name is fictitious by selecting yes or no. If yes, include the Fictitious Business Name Statement/Permit number.
5. Fill out the business address details, ensuring to include the street number, city, county, state, and ZIP code. Avoid using a PO box.
6. Provide your business telephone number, fax number, and email address for communication purposes.
7. Enter your social security number or Federal Employer ID Number (FEIN) and attach the required documentation as specified.
8. Detail the type of business structure you operate under, such as a corporation or partnership, and submit information about the principal owners.
9. Indicate your active Medi-Cal provider numbers and other health plans for which you are an active provider.
10. List the clinicians who will provide CHDP services and attach their professional licenses and qualifications.
11. Provide a description of the 24-hour on-call service availability and hospitalization arrangements.
12. Review the declaration stating that the information provided is accurate, and include the printed name, title, and signature of the Provider Applicant in blue ink.
13. Ensure to include all necessary attachments and save your completed application. You may download, print, or share the form as required.

Complete your CHDP application online today to ensure timely processing of your services.