× The federal government has shut down due to the failures of the President and Congress to continue government funding. Millions of Californians receiving benefits from state programs may be impacted. For now, California’s Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) will continue to provide services and enroll eligible families as long as funding is available. No new federal funding to California WIC will be provided until the President and Congress take action. Families should continue to use their WIC benefits and attend their WIC appointments. This information is subject to change, so please monitor the California WIC website for updates.

Please be wary of potential highly partisan political messaging while visiting federal government websites for information related to the federal government shutdown.

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Office of aids

ADAP Forms

CDPH 8445 (PDF) - Comprehensive Health Care Coverage Form

CDPH 8445 SP (PDF) - Comprehensive Health Care Coverage Form (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) Request

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

CDPH 9114 (PDF) - PrEP-AP Pharmacy User Training Request

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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