Form DHCS9052 "Genetically Handicapped Persons Program (Ghpp) New Referral Form" - California

What Is Form DHCS9052?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2007;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS9052 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS9052 "Genetically Handicapped Persons Program (Ghpp) New Referral Form" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
Genetically Handicapped Persons Program
GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP) NEW REFERRAL FORM
DATE:
CLIENT INFORMATION
NAME:
DOB:
SEX: M
F
GHPP ELIGIBLE CONDITION:
RESIDENTIAL ADDRESS:
SSN:
(OPTIONAL)
MED-CAL #:
MEDI-CARE #:
MAILING ADDRESS:
OTHER HEALTH COVERAGE:
(MEDICAL)
PHONE #:
(VISION)
MOTHER’S FIRST AND MAIDEN NAME:
(DENTAL)
BIRTHPLACE: (CITY, COUNTY, STATE/COUNTRY)
REFERRING PERSON/AGENCY:
TELEPHONE NUMBER:
FAX:
FOR CALIFORNIA CHILDREN SERVICES (CCS) USE ONLY
COUNTY:
CHILD’S CCS NUMBER:
CONTACT PERSON:
CHILD’S SPECIAL CARE CENTER:
PHONE NUMBER:
FAX NUMBER:
ATTACHMENTS (PLEASE CHECK)
MOST RECENT SCC ANNUAL REPORTS
DNA TEST RESULT OR OTHER TEST CONFIRMING GHPP ELIGIBLE CONDITION
INFORMATION ABOUT UPCOMING SURGERIES/TRANSPLANTS
PLEASE FAX TO THE GHPP AT 916-327-1112
The information requested on this form is required by the Department of Health Care Services, Children’s Medical
Services Branch, GHPP Unit for purposes of identification and enrollment processing. Failure to provide the requested
information may result in delay of GHPP enrollment.
DHCS 9052 (8/07)
State of California—Health and Human Services Agency
Department of Health Care Services
Genetically Handicapped Persons Program
GENETICALLY HANDICAPPED PERSONS PROGRAM (GHPP) NEW REFERRAL FORM
DATE:
CLIENT INFORMATION
NAME:
DOB:
SEX: M
F
GHPP ELIGIBLE CONDITION:
RESIDENTIAL ADDRESS:
SSN:
(OPTIONAL)
MED-CAL #:
MEDI-CARE #:
MAILING ADDRESS:
OTHER HEALTH COVERAGE:
(MEDICAL)
PHONE #:
(VISION)
MOTHER’S FIRST AND MAIDEN NAME:
(DENTAL)
BIRTHPLACE: (CITY, COUNTY, STATE/COUNTRY)
REFERRING PERSON/AGENCY:
TELEPHONE NUMBER:
FAX:
FOR CALIFORNIA CHILDREN SERVICES (CCS) USE ONLY
COUNTY:
CHILD’S CCS NUMBER:
CONTACT PERSON:
CHILD’S SPECIAL CARE CENTER:
PHONE NUMBER:
FAX NUMBER:
ATTACHMENTS (PLEASE CHECK)
MOST RECENT SCC ANNUAL REPORTS
DNA TEST RESULT OR OTHER TEST CONFIRMING GHPP ELIGIBLE CONDITION
INFORMATION ABOUT UPCOMING SURGERIES/TRANSPLANTS
PLEASE FAX TO THE GHPP AT 916-327-1112
The information requested on this form is required by the Department of Health Care Services, Children’s Medical
Services Branch, GHPP Unit for purposes of identification and enrollment processing. Failure to provide the requested
information may result in delay of GHPP enrollment.
DHCS 9052 (8/07)