​​​​​​​​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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