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 Laboratory Provider in the CHDP Program to the following:
1. To comply with established CHDP laws and regulations and maintain up-to-date resource materials related to
the provision of CHDP services according to program standards.
2. To maintain active Medi-Cal provider enrollment and an up-to-date Clinical Laboratory Improvement
Amendments of 1988 (CLIA) certificate.
3. To inform the local CHDP Program in writing of any changes in ownership, provider name or status, laboratory
site address, telephone, or Medi-Cal provider number, and if at all possible, 30 days in advance of the change.
4. To provide and document the following CHDP laboratory tests that have been completed at an approved
laboratory site:
Analysis of blood lead specimen if the laboratory is approved as proficient in blood lead analysis by the
California Blood Lead Proficiency Assurance Program of the Environmental Health Laboratory Branch of the
California Department of Health Services
Hematocrit and/or hemoglobin
Routine urinalysis
Sickle cell electrophoresis
PAP smear
Gonorrhea tests
Chlamydia tests
5. To refer specimens to other laboratories when proficiency testing has failed.
6. To refer families and/or patients to their health care provider for the results of the tests.
7. To participate in training from the local CHDP Program when applicable.
8. To provide requested documents to the local CHDP Program so that the Program can meet its federal
requirements to provide support services to children with suspected problems.
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.
Laboratory Director name (please print) Title
Signature (SIGN IN BLUE INK)
Laboratory Owner name (please print) Title
Signature (SIGN IN BLUE INK)
DHCS 4503 (01/08)
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