California Children's Services Forms

The following are forms for the California Children's Services Program.

If you do not see the form you need, please check if it can be ordered through the Children's Medical Services Catalog or contact us and we will try to accommodate your request.

• Application to Determine CCS Program Eligibility (DHCS 4480, 01/22)
  Alt: Spanish​ 
  
• Microsoft Business Intelligence Account Activation/Deactivation Request (DHCS 4074, 09/18)
• California Children's Services Face Sheet (MC 2142, 09/07) 
• California Children's Services Medical Report (DHCS 4014, 06/07) 
• CCS Client Dental and Orthodontic Service Authorization Request (DHCS 4516, 09/15) 
• CCS Consent for Medical/Therapy Program Services (DHCS 4027, 06/07) 
• CCS/GHPP Discharge Planning Service Authorization Request (SAR) (DHCS 4489, 09/15) 
• CCS Medical Therapy Plan (DHCS 4505, 09/07) 
• CCS Medical Therapy Program Therapy Assessment Plan (DHCS 4098, 09/07) 
• CMS Net Account Request (DHCS 4513, 05/13) 
• CMS Net County System Administrator Security and Confidentiality Oath Agreement (DHCS 9093, 05/13) 
• CMS Net Medical Therapy Program (MTP) Therapist Table (DHCS 4510, 05/13) 
• CMS Net Change Request (DHCS 4511, 05/13) 
• Communication Disorder Center Application (DHCS 4582, 02/08) 
• Established CCS/GHPP Client Service Authorization Request (SAR) (DHCS 4509, 09/15) 
• Financial Card (MC 2213, 09/07)
• Health Insurance Information (MC 2600, 09/07)
  Alt: Spanish 
• Maintenance and/or Transportation Authorization (DHCS 9086, 02/08)
  Alt: Spanish 
• Master Index Rejection Notice (DHCS 4087, 06/07)
• Medi-Cal Eligibility Data System (MEDS) Account Request (DHCS 4512, 05/13) 
• Medical Therapy Unit Summary (MC 2113 P, 09/07) 
• Narrative Sheet (MC 2320, 09/07) 
• New Referral CCS/GHPP Client Service Authorization Request (SAR) (DHCS 4488, 09/15) 
• Patient History Transaction (DHCS 4015 U, 01/08) 
• Patient Therapy Record (MC 2946, 09/07)  
• CCS Special Care Center Directory Update Form (DHCS 4507, 01/08)