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State of California—Health and Human Services Agency Department of Health Care Services
CCS Manual, Chapter 4, Attachment V
CALIFORNIA CHILDREN’S SERVICES (CCS)
CONSENT FOR MEDICAL THERAPY PROGRAM SERVICES
Medical Therapy Unit
County
I hereby authorize California Children’s Services to provide the medically necessary physical therapy and/or
occupational therapy services through the Medical Therapy Program for _____________________________.
Child’s Name
These services may include therapy evaluation, treatment, monitoring, instruction, consultation, and periodic
review by the Medical Therapy Conference team to assess the need for implementing, modifying, and/or
continuing services.
I understand that I have the right to appeal if I disagree with the CCS-approved therapy plan and that a copy of
the appeal process is attached to this form.
Signature of Parent, Caregiver, or Patient (if over 18 years of age) Relationship to Patient Date
Signature of CCS Representative Print name of CCS Representative Date
Original—File in CCS Case Record Photocopy 1—File in Medical Therapy Unit Case Record Photocopy 2—Parent copy
DHCS 4027 (06/07)
