Home Programs CHDP Manual and Bulletins

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.