Provider Forms

Additional forms can be found on the Medi-Cal Provider website.

Client Participation

Provider Participation

Requesting Services

Special Care Centers

Client Participation

• Application to Determine CCS Eligibility (English) - DHCS 4480
• Application to Determine CCS Eligibility (Spanish) - DHCS 4480(SP)

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Provider Participation

• CCS Individual Provider Paneling Application--Allied Health Care Professionals - DHCS 4515
• CCS Individual Provider Paneling Application--Physicians and Podiatrists - DHCS 4514
• Communication Disorder Center Application - DHCS 4482
• Individual and Allied Health Care Professionals - California Children's Services Change of Information Request
• Orthotic/Prosthetic Facility Application
• Outpatient Infant Hearing Screening Provider Application - DHCS 4481

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Requesting Services

• CCS Client Dental and Orthodontic Service Authorization Request - DHCS 4516
• CCS/GHPP Discharge Planning Service Authorization Request (SAR) - DHCS 4489 (7/07)
• Established CCS/GHPP Client Service Authorization Request (SAR) - DHCS 4509
• New Referral CCS/GHPP Client Service Authorization Request (SAR) - DHCS 4488 (7/07)

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Special Care Centers

• Special Care Center Directory Update Fax Cover Sheet - DHCS 4507

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