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Dhcs4480 DHCS 4480

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State of California—Health and Human Services Agency Department of Health Care Service
California Children’s Services CCS)
INFORMATION ABOUT CALIFORNIA CHILDREN’S SERVICES (CCS)
What is California Children’s Services?
CCS is a statewide program that treats children with certain physical limitations and chronic health conditions or diseases. CCS
can authorize and pay for specific medical services and equipment provided by CCS-approved specialists. The California
Department of Health Care Services manages the CCS program. Larger counties operate their own CCS programs, while smaller
counties share the operation of their program with state CCS regional offices in Sacramento, San Francisco, and Los Angeles.
The program is funded with state, county, and federal tax monies, along with some fees paid by parents.
What does CCS offer children?
If you or your child’s doctor think that your child might ha ve a CCS-eligible medical condition, CCS may pay for or provide a
medical evaluation to find out if your child’s condition is covered.
If your child is eligible, CCS may pay for or provide:
• Treatment, such as doctor services, hospital and surgical care, physical therapy and occupational therapy, laboratory tests, X-
rays, orthopedic appliances and medical equipment.
• Medical case management to help get special doctors and care for your child when medically necessary, and referral to other
agencies, including public health nursing and regional centers; or a
• Medical Therapy Program (MTP), which can provide physical therapy and/or occupational therapy in public schools for children
who are medically eligible.
Who qualifies for CCS?
The program is open to anyone who:
• is under 21 years old;
• has or may have a medical condition that is covered by CCS;
• is a resident of California; and
• has a family income of less than $40,000 as reported on the adjusted gross income on the state tax form or whose out-of-
pocket medical expenses for a child who qualifies are expected to be more than 20 percent of family income.
Family income is not a factor for children who:
• need diagnostic services to confirm a CCS eligible medical condition; or
• were adopted with a known CCS eligible medical condition; or
• are applying only for services through the Medical Therapy Program; or
• have Medi-Cal full scope, no share of cost.
What medical conditions does CCS cover?
Only certain conditions are covered by CCS. In general, CCS covers medical conditions that are physically disabling or require
medical, surgical, or rehabilitative services. There also may be certain criteria that determine if your child’s medical condition is
eligible. Listed below are categories of medical conditions that may be covered and some examples of each:
• Conditions involving the heart (congenital heart disease)
• Neoplasms (cancers, tumors)
• Disorders of the blood (hemophilia, sickle cell anemia)
• Endocrine, nutritional, and metabolic diseases (thyroid problems, PKU, diabetes)
• Disorders of the genito-urinary system (serious chronic kidney problems)
• Disorders of the gastrointestinal system (chronic inflammatory disease, diseases of the liver)
• Serious birth defects (cleft lip/palate, spina bifida)
• Disorders of the sense organs (hearing loss, glaucoma, cataracts)
• Disorders of the nervous system (cerebral palsy, uncontrolled seizures)
• Disorders of the musculoskeletal system and connective tissues (rheumatoid arthritis, muscular dystrophy)
• Severe disorders of the immune system (HIV infection)
• Disabling conditions or poisonings requiring intensive care or rehabilitation (severe head, brain, or spinal cord injuries, severe
burns)
• Complications of premature birth requiring an intensive level of care
DHCS 4480 (04/17) Page 1 of 5
State of California—Health and Human Services Agency Department of Health Care Service
California Children’s Services CCS)
• Disorders of the skin and subcutaneous tissue (severe hemangioma)
• Medically handicapping malocclusion (severely crooked teeth)
Ask your county CCS office if you have questions.
What must the applicant or family do to qualify?
Families (or the applicant if age 18 or older, or an emancipated minor) must:
• complete the application form on page 3 and return it to their county CCS office;
• give CCS all of the information requested so CCS can determine if the family qualifies;
• apply to Medi-Cal if CCS believes that a family’s income qualifies them for the Medi-Cal program. (If a family qualifies for Medi-
Cal, the child is also covered by CCS. CCS approves the services; payment is made through Medi-Cal.)
How is my privacy protected?
California law requires that families applying for services be given information on how CCS protects their privacy.
1
To protect your privacy:
• CCS must keep this information confidential.
2
• CCS may share information on the form with authorized staff from other health and welfare programs only when you have
signed a consent form.
You have the right to see your application and CCS records concerning you or your child. If you wish to see these records contact
your county CCS office. By law, the information you give CCS is kept by the program.
3
Do I have a right to appeal a decision?
You have the right to disagree with decisions made by CCS.
4 This is called an appeal. The appeal process gives the parent/legal
guardian or applicant a way to work with the CCS program to find solutions to disagreements. F or information on the appeal
process, contact your county CCS office.
Where can I get more information about CCS?
For more information, or help in filling out this application, please contact your county CCS office. Their phone number is
usually listed in the government section of your local telephone directory. Look under California Children’s Services or county
Health Department.
Notes
1 Civil Code, Section 1798.17
2 In accordance with Section 41670, Title 22, California Code of Regulations and the California Public Records Act (Government Code,
Sections 6250–6255)
3 Section 123800 et. seq. of the California Health and Safety Code
4 California Code of Regulations, Title 2, Chapter 13, Sections 42702–42703
DHCS 4480 (04/17) Page 2 of 5
State of California—Health and Human Services Agency Department of Health Care Service
California Children’s Services CCS)
APPLICATION TO DETERMINE CCS PROGRAM ELIGIBILITY
This application is to be completed by the parent, legal guardian, or applicant (if age 18 or older, or an emancipated minor) in
order to determine if the applicant is eligible for CCS services/benefits. The term "applicant" means the child, individual age
18 or older, or emancipated minor for whom the services are being requested. Please type or print clearly.
A. Applicant Information
1. Name of Applicant (last) (first) (middle) Name on birth certificate (if different) Any other name the applicant is known by
2. Date of birth (month, day, year)
3. Place of birth - county and state Country, if born outside the U.S.
4. Applicant's residence address (number, street) (do not use a P.O. Box) City County Zip Code
5. Gender 6. Race/Ethnicity
7. Social security number (optional)
8. What is the applicant's suspected eligible CCS condition or disability?
9. Primary Care Physician 10. Physician's phone number
B. Parent/Legal Guardian/Family Information (Applicants age 18 or older, or emancipated minors skip items 11 and 13.)
11. Name(s) of parent or legal guardian 12. Mother's first name (if not identified in 11) Maiden name
13. Residence address (number, street) (do not use a P.O. Box) City County Zip Code
14. Mailing address (if different from 13) City County Zip Code
15. Home phone number
( )
16. Ce ll phone number
( )
17. Work phone number
( )
18. What language do you speak at home?
19. Email address of persons in family unit 20. Number
21. Other Parent Name and Address if not living with the applicant
C. Health Insurance Information
22. Does the applicant have Medi-Cal?
Yes No
23. If yes, what is the applicants Medi-Cal
n
number?
24. Is there a share-of-cost?
Yes No
25. If yes, what is the amount you pay per month?
$
26a. Does the applicant have other health insurance?
s NoYe
26b. If yes, what is the name of the insurance plan
company or ?
26c. Policy or Plan Number
27. Type of insurance plan or company
Preferred Provider Organization (PPO) Health Maintenance Organization (HMO) Other: __________________
28. Does the applicant have dental insurance?
29. Does the applicant have vision insurance?
Yes No
Yes No
D. Certification (Initial and sign below. Your signature authorizes the CCS program to proceed with this application.)
I am applying to the CCS program in order to determine eligibility for services/benefits. I understand that the
completion of this application does not assure acceptance of applicant by the CCS program.
I give my permission to verify my residence, health information, or other circumstances required to determine
eligibility for CCS services/benefits.
I certify that I have read and understand the information or have had it read to me.
I also certify that the information I have given on this form is true and correct.
Signature of person completing the application Relationship to the applicant Date
Signature of witness (only if the person signed with a mark) Date
DHCS 4480 (04/17) Page 3 of 5
State of California—Health and Human Services Agency Department of Health Care Service
California Children’s Services CCS)
INSTRUCTIONS FOR COMPLETING THE
CALIFORNIA CHILDREN’S SERVICES APPLICATION FORM (DHCS 4480)
Please print clearly so your application can be processed as quickly as possible.
Please fill out each section completely. If you do not provide all the information, CCS will not be able to proceed with your
application. If you need help filling out this form, please contact your county CCS office.
Once the application is completed, mail it to your county CCS office. Remember to sign and date the form.
Section A: Applicant Information (”Applicant” means the child, individual age 18 or older, or emancipated minor for whom the
services are being requested.)
1. Applicant’
s name: Fill in the applicant’s last, first, and middle name. In the next Box, write the applicant’s full name as it
appears on his/her birth certificate if different from his/her name. If the applicant is known by any other name, please include
that name in the last box.
2. Applicant’s date of birth: Write the month, day, and year of the applicant’s birth.
3. Place of birth: Write the county and state where applicant was born. Include the country if the applicant was born outside the
U.S.
4. Address: Write the street number, street name, apartment number, city, county, and ZIP code of the applicant’s current
residence in this space. Please do not use a P.O. Box.
5. Applicant’s gender: Place a checkmark or an X in the correct gender box (male or female).
6. Race/Ethnicity: Please enter the category from the following list which best describes the applicant’s primary race/ethnicity:
• Alaskan Native
• Chinese
• Laotian
• Amerasian • Filipino • Samoan
• American Indian • Guamanian • Vietnamese
• Asian • Hawaiian • White
• Asian Indian • Hispanic/Latino • Other
• Black/African American • Japanese
• Cambodian • Korean
7. Applicant’s social security number (optional): Please write the applicant’s nine-digit social security number.
8. Suspected CCS condition or disability: Write the applicant’s disability or special health care need that would be treated by
CCS. The enclosed description of CCS eligible conditions may help you (see “What medical conditions does CCS cover”
on page 1). If you don’t know, ask the applicant’s doctor or leave the space blank. CCS will follow up with the applicant’s
physician if more information is needed.
9. Name of applicant’s primary care physician: Write the name of the applicant’s physician.
10. Physician’s phone number: Write the phone number for the physician listed in number 9.
Section B: Parent/Legal Guardian Information (Applicants age 18 or older, or emancipated minors skip items 11 and 13.)
11. Parent/guardian name(s): Write the name(s) of the applicant’s parent(s) or the name(s) of the applicant’s legal
guardian(s).
12. Mother’s first name and maiden name: Write the applicant’s mother’s first name and maiden name.
13. Address: Write the street number, street name, apartment number, city, county, and ZIP code of your current
residence. Please do not use a P.O. Box.
14. Mailing address: If this address is different from number 13, please write the street number, street name, city, and ZIP
code.
15. Home phone number: Please write the home phone number where you can be reached.
16. Cell phone number: Please write the cell phone number where you can be reached.
17. Work phone number: Please write the work phone number where you can be reached.
18. Language(s) spoken: Write the language you speak at home.
19. Email address: Write the email address for the parent or legal guardian.
DHCS 4480 (04/17) Page 4 of 5
20. Number of persons in family unit: Write the number of persons living in the same household.
State of California—Health and Human Services Agency Department of Health Care Service
California Children’s Services CCS)
21. Other Parent Name and Address if not living with the applicant: Write the name and address for a second
contact person.
Section C: Health Insurance Information
If CCS thinks you may qualify, they will ask you to apply for Medi-Cal if you are not c urrently receiving Medi-Cal health care
benefits.
22. If the applicant does not receive Medi-Cal, check “No” and go to number 26a. If the applicant receives Medi-Cal, check “Yes”
and fill in the applicant’s Medi-Cal number.
23. If you the applicant has Medi-Cal, enter the 14 digit Medi-Cal number.
24. If you pay a portion of the cost of your Medi-Cal insurance, check “Yes”.
25. If you pay a portion of the chare of cost, fill in the monthly amount p aid.
26a. If the applicant does not have other health insurance, check “No” and go to number 28.
26b. If the applicant has health insurance, fill in the name of the insurance plan or company.
26c. If the applicant has health insurance, fill in the policy or plan number.
27. If the applicant has health insurance, check the appropriate box depending upon what type of insurance it is. Your insurance
forms will tell you what type of health insurance you have. If you are not sure, you can call your health insurance company
and ask them.
28. If the applicant has dental insurance, check “Yes.” If the applicant does not have dental insurance, check “No.”
29. If the applicant has vision insurance, check “Yes.” If the applicant does not have vision insurance, check “No.”
Section D: Certification
Be sure to sign and date in ink. If signature is signed with a mark, please have a witness sign his or her signature and fill in the
date.
Under “Relationship to the applicant,” enter father, mother, legal guardian, or self (in the case of individuals age 18 or older, or
emancipated minors).
Submitting Your Application
Mail or deliver your application to your county CCS office. To find your county CCS office, go to www.dhcs.ca.gov/services/ccs
or look in the government section of your local telephone directory under California Children’s Services or county health
department.
DHCS 4480 (04/17) Page 5 of 5
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Completed 3 July 2020

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