Department of Health Care Services Forms

Application to determine California Children’s Services Program (CCS) Eligibility DHCS 4480 
See the CCS Forms webpage for availability in more languages.
Communication Disorder Center Application  DHCS 4482
New Referral CCS/GHPP Client SAR – NHSP Program Specific  DHCS 4488
Outpatient Infant Hearing Screening Provider Application DHCS 4481 
NHSP Early Start Referral Form

Newborn Hearing Screening Program (NHSP) Forms

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