​​​​​​​NHSP Forms

Departm​ent 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)
  To determine Region, please refer to the HCC Regional Map
• 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​