Genetically Handicapped Persons Program (GHPP) Forms

The following are forms for the Genetically Handicapped Persons Program.

If you do not see the form you need, please check if it can be ordered through the Children's Medical Services Catalog or contact us and we will try to accommodate your request.

• Account Activation/Deactivation Request - DHCS 4513
• Annual Hemophilia Comprehensive Center Evaluation - DHCS 9054
• DHCS Computer Files Release/Access of MC Program Confidential Oath - DHCS 4512
• CCS/GHPP Discharge Planning Service Authorization Request (SAR) - DHCS 4489
• CCS/GHPP Established Client Service Authorization Request (SAR) - DHCS 4509
• CCS/GHPP New Referral Client Service Authorization Request (SAR) - DHCS 4488
• GHPP Application to Determine Eligibility and Income Verification - DHCS 4000 A and B
• GHPP Application to Determine Eligibility and Income Verification - DHCS 4000 A and B (Spanish)
• GHPP New Referral - DHCS 9052
• GHPP New Referral - DHCS 9052 (Spanish)
• Request for Enteral Nutrition Product(s) - DHCS 9053
• Special Care Center Directory Update Fax Cover Sheet - DHCS 4507