Supplemental Materials

15-Day Reminder Notice
* 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)
* California Child Health and Disability Prevention Program: Consent Form (PM 211) (English/Spanish version)
CDC Growth Charts
CHDP Bright Futures Schedule for Health Assessments by Age Group
CHDP Dental Referral Classification Guide
CHDP/EPSDT Periodicity Schedule for Dental Referral by Age
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, Arabic)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Armenian)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Cambodian)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Chinese)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, English)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Farsi)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Hmong)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Korean)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Russian)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Spanish)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Tagalog)
Child Health and Disability Prevention (CHDP) Program Pre-Enrollment Application (DHCS 4073, Vietnamese)
Cover Letter
Local CHDP Directory
Recommended Vaccinations for Infants and Children
** Catch-up Immunization Schedule for Persons aged 4 months – 18 Years Who Start Late or Who are More than One Month Behind, United States, 2020
Report of Health Examination for School Entry (PM 171 A) (English/Spanish version)
Waiver of Health Examination for School Entry (PM 171 B) (English/Spanish version)

* These forms can be completed online with Adobe Acrobat Reader.
** This information appears on page two of the Recommended Childhood and Adolescent Immunizations Schedule -- United States, 2020.

Note:

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