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)
  • 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