Form DHCS4504 "Child Health and Disability Prevention (Chdp) Program Report of Distribution" - California

What Is Form DHCS4504?

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 January 1, 2009;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS4504 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 DHCS4504 "Child Health and Disability Prevention (Chdp) Program Report of Distribution" - California

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State of California – Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
REPORT OF DISTRIBUTION
Purpose of form and instruction for use:
The purpose of the report form is to confirm distribution of CHDP policy information to providers
participating in the CHDP program by the Local Health Department CHDP Program. Submission
of the report form provides documentation of the date of distribution of Provider Information
Notices.
Please ensure that the CHDP Provider Information Notice is distributed to participating CHDP
providers within 30 days of the date of release by the Children’s Medical Services (CMS) Branch.
This form is to be completed after you have distributed the CHDP Provider Information Notice.
A copy of this form is to be retained by the Local Health Department CHDP Program. Please do
not submit a copy to the CMS Branch.
PLEASE NOTE THAT NO CHANGE IS TO BE MADE IN THE PROVIDER INFORMATION NOTICE OR
ATTACHMENT.
THANK YOU.
Report of Distribution of:
CHDP Program Letter number ____________ and Provider Information Notice number______________
THIS PROVIDER INFORMATION NOTICE WAS SENT TO PROVIDERS IN
_____________________________________________________________ on ____________________
CHDP County/City Program
Date
______________________________________________________________
_______________________________________
Name of Program Representative (Print)
Title
______________________________________________________________
______________________________________
Signature of Sender
Date
Please note:
To update local program contact information (e.g., address, telephone, email address,
director or deputy director name), please follow the instructions on page one of the Children’s Medical
Services Directory. The directory can be found under “Forms and Publications” at
www.dhcs.ca.gov/chdp. To open the directory, enter the case-sensitive password: CMS#directory.
DHCS 4504 (01/09)
State of California – Health and Human Services Agency
Department of Health Care Services
Child Health and Disability Prevention (CHDP) Program
REPORT OF DISTRIBUTION
Purpose of form and instruction for use:
The purpose of the report form is to confirm distribution of CHDP policy information to providers
participating in the CHDP program by the Local Health Department CHDP Program. Submission
of the report form provides documentation of the date of distribution of Provider Information
Notices.
Please ensure that the CHDP Provider Information Notice is distributed to participating CHDP
providers within 30 days of the date of release by the Children’s Medical Services (CMS) Branch.
This form is to be completed after you have distributed the CHDP Provider Information Notice.
A copy of this form is to be retained by the Local Health Department CHDP Program. Please do
not submit a copy to the CMS Branch.
PLEASE NOTE THAT NO CHANGE IS TO BE MADE IN THE PROVIDER INFORMATION NOTICE OR
ATTACHMENT.
THANK YOU.
Report of Distribution of:
CHDP Program Letter number ____________ and Provider Information Notice number______________
THIS PROVIDER INFORMATION NOTICE WAS SENT TO PROVIDERS IN
_____________________________________________________________ on ____________________
CHDP County/City Program
Date
______________________________________________________________
_______________________________________
Name of Program Representative (Print)
Title
______________________________________________________________
______________________________________
Signature of Sender
Date
Please note:
To update local program contact information (e.g., address, telephone, email address,
director or deputy director name), please follow the instructions on page one of the Children’s Medical
Services Directory. The directory can be found under “Forms and Publications” at
www.dhcs.ca.gov/chdp. To open the directory, enter the case-sensitive password: CMS#directory.
DHCS 4504 (01/09)