State of California Health and Human Services Agency Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Maintenance and/or Transportation Authorization
To: (Name and Address)
CCS Client Name:
Date of Birth:
California Children’s Services has authorized the following transportation and/or maintenance
services for the above client and/or responsible adult caregiver:
____ Night(s) at a maximum cost of $__________ per night, at __________________.
Actual costs up to $15/day/person for ___ person(s).
Mileage Reimbursement up to maximum cost of $ . ______
Mode of Travel: _____________ up to maximum cost of $______/person for ___ person(s).
Associated Costs (e.g., parking, tolls) actual cost up to $___________.
Services Authorized for the Period of ______________ to ______________.
Additional prior authorization is needed for all additional expense requests.
Receipts are required for all claimed expense (except for gasoline which is reimbursed
based on miles of needed travel).
For reimbursement, submit receipts for all costs along with a copy of this authorization.
Submit claim and receipts within ____ days of completed travel to:
(Local CCS Program Name and Address)
If you have questions, please call CCS at ( )
Failure to comply with these requirements may result in the client/caregiver being excluded
from future use of the CCS maintenance and transportation benefit.
CCS Staff Signature
DHCS (02/08) Page 1 of 1
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