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.
• Outpatient Infant Hearing Screening Provider Application DHCS 4481
• Communication Disorder Center Application DHCS 4482
• New Referral CCS/GHPP Client SAR – NHSP Program Specific DHCS 4488
• NHSP Early Start Referral Form

Newborn Hearing Screening Program (NHSP) Forms

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