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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 date: 3/23/2021 12:30 PM
