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Forms: DHCS 4000
DHCS 4000 A (10/10) - GHPP Application to Determine Eligibility
DHCS 4000 B (10/10) - GHPP Initial/Annual Income Verification
DHCS 4001 - Family PACT Program Retroactive Eligibility Certification (REC)
DHCS 4001SP - Family PACT Program Retroactive Eligibility Certification (REC-Spanish)
DHCS 4014 (06/07) - California Children's Services Medical Report
DHCS 4015 U (01/08) - Patient History Transaction
DHCS 4026 - Incidental Medical Services Certification Form - Health Care Practitioner Client Assessment
DHCS 4027 (06/07) - CCS Consent for Medical/Therapy Program Services
DHCS 4035 A - What Does Your Child Eat?
Alt:
Instructions
DHCS 4087 - Master Index Rejection Notice
DHCS 4098 (09/07) - CCS Medical Therapy Program Therapy Assessment Plan
DHCS 4431 - Telecommunications Provider and Biller Application/Agreement
DHCS 4461 - Family PACT Program Client Eligibility Certification (CEC)
DHCS 4461SP - Family PACT Program Client Eligibility Certification (CEC-Spanish)
DHCS 4466 - Youth Nutrition and Activity Assessment--Ages 8-21
DHCS 4480 (01/08) - Application to Determine CCS Program Eligibility
Alt:
Spanish
DHCS 4483 - Customized CHDP Materials Order (currently unavailable on this webpage)
DHCS 4484 - Child Health Care Access Problem Identification (currently unavailable on this webpage)
DHCS 4488 (09/15) - New Referral CCS/GHPP Client Service Authorization Request (SAR)
DHCS 4489 (09/15) - CCS/GHPP Discharge Planning Service Authorization Request (SAR)
DHCS 4490 - Health Assessment Provider Application
DHCS 4491 - Health Assessment Provider Agreement
DHCS 4492 - Medical Record Review Tool
DHCS 4493 - Facility Review Tool Scoring Instructions
DHCS 4494 - Facility Review Scoring Summary Sheet
DHCS 4502 - Laboratory Provider Application
DHCS 4503 - Laboratory Provider Program Agreement
DHCS 4504 - Report of Distribution
DHCS 4505 (09/07) - CCS Medical Therapy Plan
DHCS 4507 (01/08) - CCS Special Care Center Directory Update Form
DHCS 4509 (09/15) - Established CCS/GHPP Client Service Authorization Request (SAR)
DHCS 4510 (05/13) - CMS Net Medical Therapy Program MTP Therapist Table
DHCS 4512 (05/13) - DHCS Computer Files Release/Access of MC Program Confidential Oath
DHCS 4516 (09/15) - CCS Client Dental and Orthodontic Service Authorization Request
DHCS 4582 (02/08) - Communication Disorder Center Application
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Last modified date: 8/22/2025 9:28 AM
