Intellect™
CHDP CLAIM FORM PM 160
Listed below are Place of Service (POS) Codes and Corresponding Descriptions to be used when Billing CHDP services.
POS Code Description
11 Office (any location other than Place of Service code 22 or 71)
22 Outpatient Hospital
71 State or Local Public Health Clinic
72 Rural Health Clinic
81 Independent Laboratory
99 Other
RELEASE OF INFORMATION NOTICE TO THE RESPONSIBLE PERSON:
The information provided on this form is voluntary and is used by the California Child Health and Disability Prevention (CHDP) program in accordance with Article 7, Subchapter 13, Title 17, of the California Administrative Code to monitor program quality, to reimburse providers of health assessments for their services, and to facilitate diagnosis and treatment
at the local level for children found to have health problems. Information provided may be transferred to local health departments for follow-ups. Refusal to supply the information requested will hamper efforts to monitor this program, may delay reimbursement procedures, and may delay diagnosis and treatment of health conditions affecting your child. For access
to records containing this information, you may contact the individual listed below. You may also request the location of this information and the categories of persons who use it.
Chief, Children’s Medical Services
Department of Health Care Services
MS 8100
1515 K Street, Suite 400
Sacramento, CA 95814
(916) 327-1400
PM 160
06/07