Forms

Department of Health Care Services Forms

Newborn Hearing Screening Program Forms

Department of health Care services forms

• Application to determine CCS Program Eligibility  English | Spanish  DHCS 4480 (PDF)
• Communication Disorder Center Application  DHCS 4482 (PDF)
• New Referral CCS/GHPP Client SAR - NHSP Program Specific  DHCS 4488 (PDF)
• Outpatient Infant Hearing Screening Provider Application  DHCS 4481 (PDF)

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newborn hearing screening program (NHSP) forms

• Brochure Order Forms 
• Military Consent for Release and Exchange of Information Form - NHSP 700-1 (PDF)
• Diagnostic Audiologic Evaluation Reporting Form - NHSP 300-1 (Region Specific)
  To determine Region, please refer to the HCC Regional Map
  Region A   (PDF)
  Region B   (PDF)
  Region C   (PDF)
  Region D   (PDF)
• Infant Reporting Form - NHSP 100-1 (Region Specific)
  Region A   (PDF)
  Region B   (PDF)
  Region C   (PDF)
  Region D   (PDF)
• Outpatient Screening Reporting Form - NHSP 200-1 (Region Specific)
  Region A   (PDF)
  Region B   (PDF)
  Region C   (PDF)
  Region D   (PDF)
• Request Service Form has been updated to the: 
  New Referral CCS/GHPP Client SAR - NHSP Program Specific   DHCS 4488 (PDF)

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