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ADAP Forms

CDPH 8445 (PDF) - 2018 Comprehensive Health Care Coverage

CDPH 8445 SP (PDF) - 2018 Comprehensive Health Care Coverage (Spanish)

CDPH 8720 (PDF) - Agreement by Employee/Contractor to Comply with Confidentiality Requirements

CDPH 8723 (PDF) - Client Attestation

CDPH 8723 SP (PDF) - Client Attestation (Spanish

CDPH 8444 (PDF) – Client Handout form

CDPH 8730 (PDF) - Confidential Fax Submission

CDPH 8685 (PDF) - Consent Form

CDPH 8685 SP (PDF) - Consent Form (Spanish)

CDPH 8440 (PDF) –Diagnosis Form

CDPH 8729 (PDF) - Eligibility Exception Request (EER)

CDPH 8439 (PDF) - Enrollment Application

CDPH 8439 SP (PDF) - Enrollment Application (Spanish)

CDPH 8542 (PDF) - Grievance Form

CDPH 8542 SP (PDF) - Grievance Form (Spanish)

CDPH 8441 (PDF) - Income Verification Affidavit

CDPH 8441 SP (PDF) - Income Verification Affidavit (Spanish)

CDPH 8724 (PDF) - Medi-Cal Eligibility Exception Request (MEER)

CDPH 8731 (PDF) - New Enrollment Worker Training Request form

CDPH 8442 (PDF) - Provider Verification of Identify

CDPH 8727 (PDF) - Residency Verification Affidavit

CDPH 8727 SP (PDF) - Residency Verification Affidavit (Spanish)

CDPH 8456 A (PDF) - Revocation of Special Power of Attorney

CDPH 8726 (PDF) - Self Employment Affidavit

CDPH 8726 SP (PDF) – Self-Employment Affidavit (Spanish)

CDPH 8456 (PDF) - Special Power of Attorney

 CDPH 8728 (PDF) - Temporary Access Period (TAP)

OA HIPP Forms

CDPH 8738 (PDF) - Acknowledgement of Policies and Responsibilities Health Insurance Premium Payment (HIPP) Program Family Plan

 CDPH 8732 (PDF) - Client Responsibilities form

CDPH 8732 SP (PDF) - Client Responsibilities form (Spanish)

CDPH 8737 (PDF) - Family Plan Consent Form

CDPH 8443 (PDF) - Medical Out-of-Pocket Claim form

CDPH 8443 SP (PDF) - Medical Out-of-Pocket Claim Form (Spanish)

CDPH 8722 (PDF) - Partial Payment Agreement form

CDPH 8722 (PDF) - Partial Payment Agreement form (Spanish)

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