Provider: Administrative Forms

CHDP Program Forms

• Provider Application (DHS 4490)
• Health Assessment Provider Agreement (DHS 4491)
• Medical Record Review Tool (DHS4492)  Medical Record Review Guidelines
• Facility Review Tool (DHS4493)
• CHDP 171A (Report of School Health Exam)  
• Nutrition Assessment Form (DHS4035)
  • English
  • Spanish  

 

• California Pediatric TB Referral Form 
• CHDP Pre-Participation History Form
• CHDP Pre-Participation Exam Form
• CHDP Provider Foster Care Medical Contact Form
• CHDP Provider Care Coordination Reporting Form

 

Referral Programs Forms

CCS (California Children’s Services)

• SAR (Service Authorization Request) (DHS4488)
• Application for Services
  • English                   
  • Spanish               
  • Vietnamese    

Help Me Grow

• Referral Materials
• Help Me Grow On-Line Application

Regional Center of Orange County - call for application (714) 796-5354
WIC

• WIC Referrals (Women, Infants and Children)

Health Care Programs  

Health Care Matrix

• English              
• Spanish        
• Vietnamese
• Korean
• Kaiser Child Health Plan

1. Updated 7-8-19