Skip to Main Content
  • Home
  • #
  • #
  • #
  • Home
  • About DHCS
  • Translate
CA.gov logo
DHCS logo
Menu Search
  • Home
  • Services
  • Individuals
  • Providers &
    Partners
  • Laws &
    Regulations
  • Data &
    Statistics
  • Forms &
    Publications
  • Search
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 date: 6/19/2020 2:28 PM


Non-Discrimination Policy and Language Access

Access Health Care Language Assistance Services (SB 223)


العربية   |   Հայերեն   |   ខ្មែរ   |   繁體中文   |   فارسی   |   हिंदी   |   Hmoob   |   日本語   |   한국어   |   ລາວ   |   ਪੰਜਾਬੀ   |   Русский   |   Español   |   Tagalog   |   ภาษาไทย   |   Tiếng Việt


About Us   |   Careers   |   Conditions of Use   |   Privacy Policy   |   Contact Us   |   Accessibility Certification

Copyright © State of California