State of California—Health and Human Services Agency Department of Health Care Services
California Children’s Services
PATIENT HISTORY TRANSACTION
Trans. code State file number Patient name Last First M.I.
Birth date (month/day/year) Sex Race
1—Male 1—White 3—Spanish surname 5—American Indian 7—Other Nonwhite
2—Female
2—Black 4—Asian 6—Filipino 8—No response
3—Unknown 9—Unknown
Reporting county Residence county (if different than reporting county)
Birth place—county or state or other country Mother’s maiden name
Presumptive CCS
Eligible Dx
Referral source Referral date (month/day/year)
1—Parent 4—Other provider 7—School
2—Hospital 5—CHDP/EPSDT 8—DD regional center
3—Physician 6—CCS case finding 9—Other
Disposition of case Completed by / date
1—Diagnosis only 3—Diagnosis and waiting list
2—Diagnosis and treatment 4—Therapy only
ES DO NOT SUBMIT CHANGES OR CLOSUR
RM
D
O FION OFON THIS PORT
CASE OPENEREPORT OF
FILE COPY
Changes or closures are to be made on a photocopy of this transaction!
DO NOT enter changes or closures on the original copy of this transaction!
Notice of Change of Information
(Enter only information to be changed.)
Reopen case
Patient name 1.
(last)
2.
(first)
3.
(m.i.)
Birth date 4.
(month/day/year)
Sex 5.
1—Male 2—Female 3—Unknown
Race 6.
1—White 4—Asian 7—Other Nonwhite
2—Black 5—American Indian 8—No response
3—Hispanic 6—Filipino 9—Unknown
Reporting county 7.
Residence county 8.
Birth place 9.
(county, state, or other country)
Mother’s
maiden name 10.
(last name only)
Presumptive Dx 11.
a. b.
c. d.
Referral source 12.
1—Parent 4—Other provider 7—School
2—Hospital 5—CHDP/EPSDT 8—Regional center
3—Physician 6—CCS case finding 9—Other
Referral date 13.
Month Day Year
Report of Case Closure
(enter code here)
Reasons for case closure (use one only)
01—Treatment completed
02—Eligible condition cured
03—No treatment indicated at this time
04—Patient reached 21 years of age
05—Residence established in another county
06—Residence established in another state
07—No response at last known address
08—Medically ineligible
09—Financially ineligible
10—Parents will handle privately
11—Referred to another treatment source
12—Death of patient
13—Family covered by prepaid health plan
14—Unable to keep appointments
19—Other (specify)
Effective date of closure
month day year
County
Source of information
Completed by
Date
PRIVACY NOTIFICATION
This information is requested by the California Children’s Services Program of the State Department of Health Care Services, under Section 123800 et seq. of the California
Health and Safety Code, in order to provide medical treatment services. Completion of the form is required and services may be denied when not providing the information.
Information will be provided to the State Department of Health Services and the county in which you reside. For more information or access to your records, contact Children’s
Medical Services, Program Support Section, P.O. Box 997413, MS 8100, Sacramento, CA 95899-7413; telephone (916) 327-1400.
DHCS 4015 U (01/08)
