Chdp Provider Data Sheet

California Child Health and Disability Prevention (CHDP ...

Reviewed by CHDP Director (print name) Signature Date signed Date CHDP Provider Data Sheet (PM 177) sent to State DHCS 4490 (01/08) Page 1 of 4 . 16. Clinical Laboratory Improvement Amendment (CLIA) (check one): CLIA waiver …

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