State of California—Health and Human Services Agency Department of Health Care Services
Children’s Medical Services Branch
California Child Health and Disability Prevention (CHDP) Program
I, the undersigned, agree as a Health Assessment Provider in the CHDP program to the following:
1. To comply with established CHDP program laws and regulations and maintain up-to-date resource materials related to
the provision of CHDP services according to program standards.
2. To complete and document the following CHDP assessment procedures within the approved business address: history
and complete physical exam with dental/oral health inspection, developmental assessment, nutritional evaluation,
anticipatory guidance, vision screening test (e.g., Snellen or equivalent), puretone audiometric screening, immunizations,
tuberculin (PPD) skin test, and urine dipstick for blood, protein, glucose.
3. To complete and document the following CHDP assessment procedures with the understanding that these tests may be
referred out to another provider: hematocrit and/or hemoglobin, routine urinalysis, sickle cell electrophoresis, pelvic
exam, PAP smear, gonorrhea tests, chlamydia tests, ova/parasites test, blood lead, or other testing.
4. To participate in training from the local CHDP program.
5. To provide follow-up information when requested by the local CHDP program.
6. To participate in periodic visits from the local CHDP program to evaluate compliance with CHDP program laws and
7. To provide a health assessment summary or immunization information to the child’s parents or legal guardian at no cost
and upon request or when required. This information may include school health reports, immunization records, and any
such information required by the Head Start or Women, Infants, and Children programs.
8. To provide the following services as a Comprehensive Care Provider and document these activities:
a. Assume the responsibility for diagnosis and treatment when indicated.
b. Coordinate additional care as needed.
c. Make medical and dental referrals as needed.
d. Provide continuity of care.
e. Provide reasonable follow-up on missed appointments.
9. To provide the following services as a Health Assessment Only Provider and document these activities:
a. Assume the responsibility for referral for diagnosis and treatment to a Comprehensive Care Provider.
b. Make dental referrals.
c. Make a reasonable attempt to determine if referrals were completed.
10. To comply with the Child Abuse and Neglect Reporting Act (Penal Code Section 11164 et seq).
11. To maintain active enrollment as a Medi-Cal provider.
I declare under penalty of perjury under the laws of the State of California that all information and attachments are true,
accurate, and complete to the best of my knowledge and belief.
NOTE: Provider Applicant name/signature below means the name and title of the Provider Applicant indicated in number 1 of
the CHDP Health Assessment Provider Application (DHCS 4490). An original signature in blue ink is required. Indicate the
date the program agreement is signed.
Provider applicant name (please print) Title
Signature (sign in blue ink)
DHCS 4491 (01/08)