Children’s Presumptive Eligibility Pre-Enrollment Worksheet Update
| Date: | February 11, 2026 |
| From: | Health Plan of San Joaquin/Mountain Valley Health Plan (“Health Plan”) |
| To: | Health Plan Providers |
| Type: | Procedural Update |
| Subject: | Children’s Presumptive Eligibility Pre-Enrollment Worksheet Update |
| Business: | Medi-Cal Managed Care |
The Children’s Presumptive Eligibility Pre-Enrollment Worksheet (DHCS 4073) is a tool used by qualified providers to collect applicant information and reference when completing an online enrollment transaction.
The worksheet has been updated to communicate mandatory fields with an asterisk (*). No other content has changed. Worksheets in all threshold languages are on the Children’s Presumptive Eligibility (CPE) web page found here: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/references/cpe.
Effective immediately, providers should discontinue use of previous versions and only use those with an 11/2024 revision date.
Reminder: The “Application Summary” generated during the enrollment process stands as the only valid form of the application and must be reviewed and signed before submission. Once reviewed and signed, a signed copy must be given to the family, and another stored in the patient’s record.
Questions about the Children’s Presumptive Eligibility Pre-Enrollment Worksheet can be sent to ChildrenPE@dhcs.ca.gov.
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website www.hpsj-mvhp.org
