WWW.PRIMECLINICAL.COM

 

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

 

Top of Page