Appendix: Supplemental Materials

Contents

CHDP BILLING AND POLICY

The Appendix: Supplemental Materials Contents is a list of sample forms, letters and resources that are referenced in the Child Health and Disability Prevention (CHDP) program manual. Please note the following:

  • Documents in the Appendix are for illustration only and may not be photocopied for use, unless otherwise indicated in the related policy section in this manual.
  • All documents listed in this Appendix are available on the CHDP Web site at

and on the Medi-Cal Web site at , unless an

alternative Web site is identified. Web sites are listed for downloadable forms.

  • Documents generally are listed in alphabetical order by the full, official title that appears on the document.

Document Title

15-Day Reminder Notice

A

Aid Codes Master Chart

American Dental Association’s “Classification of Treatment Needs”

Asian and Pacific Islander Groups Reported in the 1980 Census

C

California Child Health and Disability Prevention (CHDP) Program:

CHDP Health Assessment Provider Application (DHCS 4490)

California Child Health and Disability Prevention (CHDP) Program:

CHDP Laboratory Provider Application (DHCS 4502)

California Child Health and Disability Prevention (CHDP) Program:

Health Assessment Provider Program Agreement (DHCS 4491)

California Child Health and Disability Prevention (CHDP) Program:

Laboratory Provider Program Agreement (DHCS 4503)

Appendix: Supplemental Materials Contents 1 CHDP 40

February 2008

Document Title

California Child Health and Disability Prevention Program:

Consent Form (PM 211) (English version)

California Child Health and Disability Prevention Program:

Consent Form (PM 211) (Spanish version)

Centers for Disease Control and Prevention Growth Charts – Body Mass

Index-for-Age Percentiles: Boys, 2 to 20 Years

access at

Centers for Disease Control and Prevention Growth Charts – Body Mass

Index-for-Age Percentiles: Girls, 2 to 20 Years

access at

Change in Provider Information Letter

CHDP Bright Futures Schedule for Health Assessments by Age Groups

CHDP Confidential Referral/Follow-up Report (PM 161)

CHDP/EPSDT Periodicity Schedule for Dental Referral by Age

CHDP Provider Approval Letter (Sample Letter)

Child Health and Disability Prevention (CHDP) Program:

Facility Review Tool Scoring Instructions (DHCS 4493)

Child Health and Disability Prevention (CHDP) Program:

Medical Record Review Tool Scoring Instructions and Reviewer Guidelines

(DHCS 4492)

Child Health and Disability Prevention (CHDP) Program:

Pre-Enrollment Application (DHCS 4073) (English version)

Arabic, Armenian, Cambodian, Chinese, Farsi, Hmong, Korean, Russian, Spanish, Tagalog and Vietnamese versions – access on Internet at CHDP Web site at

Confidential Morbidity Report (PM 110)

access on Internet at California Department of Public Health Web site

Confidential Screening/Billing Report (PM 160)

Confidential Screening/Billing Report (PM 160 Information Only)

Cover Letter

Appendix: Supplemental Materials Contents 1 CHDP 143

September 2016

Document Title

I

Immunization Record (PM 298)

not available online for downloading

Important Information About the Child Health & Disability Prevention (CHDP)

Gateway to Health Coverage

L

Local CHDP Directory

latest version available on Internet at CHDP Web site at

P

Periodicity Schedule for Dental Referral by Age

Periodicity Schedule for Health Assessment Requirements by Age Groups

Post-Visit Flyer

(see Your Child Now Has Free Temporary Medi-Cal Health Coverage)

Pre-Visit Flyer

(see Important Information About the Child Health & Disability Prevention (CHDP) Gateway to Health Coverage)

R

Recommended Childhood and Adolescent Immunizations Schedule -- United States, 2006

access on Internet at Centers for Disease Control and Prevention Web site,

or

Immunization Action Coalition Web site,

For Children and Adolescents Who Start Late or Who Are > 1 Month Behind

access on Internet at Centers for Disease Control and Prevention Web site,

or

Immunization Action Coalition Web site,

Report of Health Examination for School Entry (PM 171 A) (English version)

Report of Health Examination for School Entry(PM 171 A) (Spanish version)

Appendix: Supplemental Materials Contents 1 CHDP 53

March 2009

Document Title

W

Waiver of Health Examination for School Entry (PM 171 B) (English version)

Waiver of Health Examination for School Entry (PM 171 B) (Spanish version)

Y

Your Child Now Has Free Temporary Medi-Cal Health Coverage

Appendix: Supplemental Materials Contents 1 CHDP

June 2003