Provider Forms
Additional forms can be found on the Medi-Cal Provider website.
Client Participation
Application to Determine CCS Eligibility (English) – DHCS 4480
See the California Children’s Services Forms webpage for availability in more languages.
Provider Participation
- Communication Disorder Center Application – DHCS 4482
- Outpatient Infant Hearing Screening Provider Application – DHCS 4481
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)