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State of California Health and Human Services Agency Department of Health Care Services Children s Medical Services CHIP PROVIDER DATA SHEET For Local CHIP Program Use Only Local CHIP Program: Date:
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How to fill out chdp what is form:

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First, gather all the necessary information and documents required to complete the form.
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Begin filling out the form by entering your personal information, such as your name, address, and contact details.
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Provide any additional information that is specifically requested on the form, such as your date of birth or social security number.
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Fill in the details of your healthcare provider, including their name, address, and contact information.
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Complete the sections related to your child's medical history, including any existing conditions or disabilities they may have.
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The Child Health and Disability Prevention (CHDP) program is designed for children and youth from low-income families in California.
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Related Links

CHDP PROVIDER DATA SHEET For Local CHDP Program ...
Please complete, as necessary, all of the corresponding data elements on the PM 177. This form is to be completed by the local CHDP Program only.
CHDP DIRECTOR/DEPUTY DIRECTOR TRAINING SECTION II ...
Dec 17, 2015 ... Slide 1 CHDP DIRECTOR/DEPUTY DIRECTOR TRAINING SECTION II ... Notifying CMS Branch of Provider Info CHDP Provider Data Sheet (PM 177) ... The Form used to request access can be found at the CHDP website, ...
Santa Barbara County Senior Resource Directory - Central ...
to the front section of the white pages of your local telephone ... Locator Service, go to www dhcs ca gov Call for information about ... 805-280-4490 www picf org.

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