Fillable Dhcs4482 Communication Disorder Center Application

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Dhcs4482 Communication Disorder Center Application

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State of California—Health and Human Services Agency Department of Health Care Services
California Children Services
DHCS 4482 (2/08)
Page 1 of 4
COMMUNICATION DISORDER CENTER APPLICATION
NOTE: Please review the CCS Standards for Communication Disorder Centers, (CCS Manual of Procedures, Chapter 3.40) for the specific
requirements of the program. Attach any additional information about your program which you believe will be of interest and assistance to
CCS in evaluating your facility. A facility will be evaluated by a review of this application, a site visit or both.
Name of Facility
Name of hospital/medical center (if different from above)
Medi-Cal provider number
NPI number
Telephone number
FAX
TDD
Address
City
ZIP code
Service Address
City
ZIP code
County
Director
E-mail address
Chief audiologist
E-mail address
Contact person for this application
Telephone number
FAX
E-mail address
CCS APPROVAL REQUESTED—Communication Disorder Center
Type A
Type B
Type C
PERSONNEL*
1. Audiology Staff (Attach Curriculum Vitae for each professional staff member.)
Name Degree
CA Audiology License/
HA Disp. License Number
On-site Hours
at this Facility
Years of
Experience
Including CFY
CCS
Paneled
Provider?*
Yes
No
Yes
No
Yes
No
Yes
No
* Audiologists and Speech Pathologists are required to complete the CCS panel application (DHCS 4515
) if they are not already on the CCS panel.
2. Speech Language Pathology Staff* (Attach Curriculum Vitae for each professional staff member.)
Name Degree CA SLP License Number
On-site Hours
at this Facility
Years of
Experience
Including CFY
CCS
Paneled
Provider?*
Yes
No
Yes
No
* Audiologists and Speech Pathologists are required to complete the CCS panel application (DHCS 4515
) if they are not already on the CCS panel.
3. Other Staff* (Including Teacher of the Deaf, Test Assistant, Social Worker)
Name Position Qualifications
On-site Hours
at this Facility
DHCS 4482 (2/08) Page 2 of 4
*If professional staff members do not provide services at this facility, please identify their location and the process for referral:
OPEN FOR SERVICE
Days
Hours
Specific periods not open for service
SERVICES OFFERED AT YOUR FACILITY (Please check those that apply.)
Hearing Speech
1. Diagnostic Evaluation
2. Hearing Aid Evaluation
3. Hearing Aid Dispensing
4. Audiometric Screening
5. Outpatient Infant Hearing Screening Services (Chapter 3.42)
6. Cochlear Implants
7. Speech Therapy
8. Infant/Preschool Habilitation Program
9. Parent Education Program
10. Aural Rehabilitation
11. Counseling
EQUIPMENT
Type of Equipment Used Yes No Manufacturer Model/Serial Number
1. Clinical Audiometer
2. Infant Hearing Screening Equipment
3. ABR
Screening
Diagnostic
Click
Toneburst
Bone Condition
4. OAE
Screening
TEOAE
DPOAE
Diagnostic
TEOAE
DPOAE
Other technology:
DHCS 4482 (2/08) Page 3 of 4
CALIBRATION OF AUDIOLOGICAL EQUIPMENT
1. Who is responsible for maintaining calibration of audiological equipment?
2. How are calibration records kept?
AUDIOMETRIC TEST ROOM(S)
Size (Width X Length) Manufacturer Model
X
X
CLINICAL PRACTICES
1. Who is responsible for maintaining clinical records on each patient?
2. Who is responsible for developing and maintaining Policy and Procedures Manual?
CASE CONFERENCES
Describe provisions for case conferences, care coordination, and consultation among the center personnel identified in Section C of this
application (Type B and Type C Centers only) of the Communication Disorder Center Standards.
WILL BE INITIATED UPON CCS APPROVAL
Describe your program for habilitating deaf/hard of hearing children under 5 years of age (Types B and C only).
WILL BE INITIATED UPON CCS APPROVAL
WHERE ARE SEDATION SERVICES PERFORMED
Name of facility
Who is responsible for oversight of administration of sedation
Medi-Cal provider number (if known)
DHCS 4482 (2/08) Page 4 of 4
I AGREE THAT THIS FACILITY WILL:
1. Refer all children with a CCS-eligible condition to the CCS program.
2. Comply with the CCS requirements including staffing, facility, equipment, and calibration standards.
3. Comply with CCS requirements for care coordination/referral.
4. Accept patients authorized by CCS including those who have Medi-Cal coverage.
5. Submit timely reports to the CCS program on children for whom care is authorized.
6. Bill insurance first (within 2 months of the month of service) before billing CCS or Medi-Cal.
7. Bill CCS within 2 months of service, insurance payment or insurance rejection. (Bill CCS within 12 months of the date of service if
insurance fails to respond.)
8. Bill CCS on the Medi-Cal claim form.
9. Accept payment in accordance with state regulations as payment in full.
10. Not bill families in whole or part for any CCS covered benefit.
11. Not question families regarding their ability to pay for CCS covered services.
12. Keep CCS informed of any changes affecting participation in the CCS program.
13. Request prior authorization for services to be covered by CCS.
Application completed by Position
Signature of director or chief audiologist Date
RETURN TO: Attention: Unit Manager
Hearing and Audiology Services Unit
Children’s Medical Services Branch , MS 8103
Department of Health Care Services
P.O. Box 997413
Sacramento, CA 95899-7413
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Completed 3 July 2020

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