You may be trying to access this site from a secured browser on the server. Please enable scripts and reload this page.
Turn on more accessible mode
Turn off more accessible mode
Skip Ribbon Commands
Skip to main content
This page location is:
Home
Services
California Children's Services
Pages
ProviderForms
Sign In
California Children's Services
This Site
This List
Top Link Bar
Home
Home
Services
Currently selected
Administrative
CAASD
California Children's Services
Cancer
Child Health and Disability Prevention
Clinical Preventive Medicine
Family Planning
Genetically Handicapped Persons
HCPCFC
Hearing Conservation Program
Long-Term Care
Medi-Cal
Mental Health
Multicultural Health
Newborn Hearing Screening Program
Pediatric Palliative Care Waiver
Rural Health (Indian Health, Rural Health)
Individuals
Children and Teenagers
Women's Health
Seniors
Men's Health Information
Fraud and Abuse
Persons with Disabilities
Find out if I Qualify
Locate the Nearest County Office
Enrollment Forms
California PACE Plans
Senior Care Action Network
Health Plan Directory
Audits & Investigations
Internal Audits
What is Fraud?
Stop Medi-Cal Fraud | Administrative Sanctions
Criminal Convictions | Stop Medi-Cal Fraud
Stop Medi-Cal Fraud Complaint Form
Frequently Asked Questions
Resources
Providers & Partners
Initiatives
County Information
Pharmacy
POS
RFA/RFP
08/09 Time Survey Training Materials
10501 - Definitions
1115 Behavioral Health Services Needs Assessment
1115 Waiver Archive
1115 Waiver Renewal Main Page
1115 Waiver Renewal Official Submission
1115 Waiver Renewal Webinar
1115 Waivers for other states
1115 WR Kick Off Webinar
12-13 Annual Report/PPA (New Provider)
12-13 Annual Report/PPA (Returning Providers)
2006-2007 Annual Report
2007-2008 Annual Report Templates
Forms, Laws & Publications
Publications
Forms
Laws
1996 Policy and Procedure Letters
1997 Policy and Procedure Letters
1998 Policy and Procedure Letters
1999 Policy and Procedure Letters
2000 Policy and Procedure Letters
2001 Policy and Procedure Letters
2002 Policy and Procedure Letters
2003 Policy and Procedure Letters
2004 Policy and Procedure Letters
2005 Policy and Procedure Letters
2006 Policy and Procedure Letters
2007 Policy and Procedure Letters
2008 Policy and Procedure Letters
2009 Policy and Procedure Letters
2010 Policy and Procedure Letters
2011 Policy and Procedure Letters
2012 Policy and Procedure Letters
Data & Statistics
AI
Data
Reports
Statistics
Adolescent Well-Care visits
Annual Monitoring for Patients on Persistent Medications
California Women's Health Survey
Cervical Cancer Screening
Childhood Immunization Status
Children and Adolescents’ Access to Primary Care Practitioners
Chlamydia Screening in Woman
CMS Initial Adult Core Measures
CMS Initial Children Core Measures
Controlling High Blood Pressure
Core Set Measures Reporting
External Data Resources
HbA1c Testing
Healthy Families Historical Reports
Immunizations for Adolescents
Medi-Cal 50th Anniversary
Search
Skip to:
Content
|
Footer
|
Accessibility
California Department of Healthcare Services
Help
Career Opportunities
Contact Us
Home
Services
Individuals
Providers & Partners
Forms, Laws & Publications
Data & Statistics
Search for this site:
Home
>
Services
>
California Children's Services
>
Provider Forms
Quick Launch
Administrative
CAASD
California Children's Services
Currently selected
CMS Net
Special Care Centers
Know the Benefits
Find out if I Qualify
How To Apply
Medical Eligibility
Becoming a CCS Provider
HIPAA
Medical Authorizations & Claims
CCS Information Brochure
Regional Cooperation Agreement
High Risk Infant Follow Up
Provider Standards
Letters
CCS Information Notices
CCS Numbered Letters
Provider Web Links
Family Resources
Medical Therapy Program
Program Overview
Cancer
Child Health and Disability Prevention
Clinical Preventive Medicine
Family Planning
Genetically Handicapped Persons
HCPCFC
Hearing Conservation Program
Long-Term Care
Medi-Cal
Mental Health
Multicultural Health
Newborn Hearing Screening Program
Pediatric Palliative Care Waiver
Rural Health (Indian Health, Rural Health)
Page Content
Provider Forms
Additional forms can be found on the
Medi-Cal Provider website
.
Client Participation
Application to Determine CCS Eligibility (English) - DHCS 4480
Application to Determine CCS Eligibility (Spanish) - DHCS 4480(SP)
Provider Participation
Communication Disorder Center Application - DHCS 4482
Outpatient Infant Hearing Screening Provider Application - DHCS 4481
Requesting Services
CCS Client Dental and Orthodontic Service Authorization Request - DHCS 4516
CCS/GHPP Discharge Planning Service Authorization Request (SAR) - DHCS 4489 (7/07)
Established CCS/GHPP Client Service Authorization Request (SAR) - DHCS 4509
New Referral CCS/GHPP Client Service Authorization Request (SAR) - DHCS 4488 (7/07)
Special Care Centers
CCS Special Care Center Directory Update Sheet
(DHCS 4507)
Last modified on: 10/5/2018 10:06 AM