Fillable Dhcs4489 CCS/GHPP Discharge Planning Service Authorization Request (SAR)

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Dhcs4489 CCS/GHPP Discharge Planning Service Authorization Request (SAR)

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The Dhcs4489 CCS/GHPP Discharge Planning Service Authorization Request (SAR) form is 2 pages long and contains:

  • 0 signatures
  • 11 check-boxes
  • 100 other fields

Country of origin: US
File type: PDF

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State of California—Health and Human Services Agency Department of Health Care Services
California Children’s Services/Genetically Handicapped Persons Program
CCS/GHPP DISCHARGE PLANNING SERVICE AUTHORIZATION REQUEST (SAR)
Hospital Information
1. Date of request
2. Hospital name
3. Provider number
4. Address (number, street)
City
State ZIP code
5. Contact person/discharge planner
6. Telephone number
( )
Client Information
8. Client name—last
first
middle
9. Alias (AKA)
10. Gender
Male Female
11. Date of birth (mm/dd/yyyy)
12. CCS/GHPP case number
13. Medical record number (hospital or office)
14. Home phone number
( )
15. Cell phone number
( )
16. Work phone number
( )
17. Email address
18. Residence address (number, street) (DO NOT USE P.O. BOX)
City
State ZIP code
19. Mailing address (if different) (number, street, P.O. box number)
City
State ZIP code
20. County of residence
21. Language spoken
22. Name of parent/legal guardian
23. Mother’s first name
24. Primary care physician (if known)
25. Primary care physician telephone number
( )
Insurance Information
26.a. Enrolled in Medi-Cal?
Yes No
26.b. If yes, client index number (CIN)
26.c. Client’s Medi-Cal number
27. Enrolled in commercial insurance plan?
Yes No
If yes, type of commercial insurance plan
PPO HMO Other
Name of plan
28. Diagnosis
29.
Plan to discharge to:
Home
Transfer to (specify):
Specific Discharge Planning Services Requested
30.
Provider’s name
Provider number
Telephone number
( )
Contact person
Address
City
State ZIP code
EPSDT SS?
Yes No
Procedure code
Units
Provider number
Telephone number
( )
Description of services
Quantity
Additional information
Frequency/duration
31. Provider’s name
Contact person
Address
City
State ZIP code
Description of services
EPSDT SS?
Yes No
Procedure code
Units
Quantity
Additional information
Frequency/duration
32. Signature of discharge planner
33. Title
34. Name of discharging physician
35. Date
DHCS 4489 (09/15)
Page 1 of 3
36. Client name—last
first
middle
37. Date of request
38. Contact person/discharge planner
39. Telephone number
( )
Specific Discharge Planning Services Requested (continued)
40.
Provider’s name
Provider number
Telephone number
Contact person
( )
Address
City
State ZIP code
41.
Description of services
Additional information
Provider’s name
EPSDT SS?
Procedure code
Yes No
Frequency/duration
Provider number
Telephone number
( )
Units
Contact person
Quantity
Address
City
State ZIP code
Description of services
EPSDT SS?
Yes No
Procedure code
Units
Quantity
Additional information
Frequency/duration
Privacy Statement (Civil Code Section 1798 et seq.)
The information requested on this form is required by the Department of Health Care Services for purposes of identification and document processing. Furnishing the
information requested on this form is mandatory. Failure to provide the mandatory information may result in your request being delayed or not be processed.
42. Signature of discharge planner
43. Title
44. Name of discharging physician
45. Date
DHCS 4489 (09/15)
Page 2 of 3
INSTRUCTIONS
1. and 35. Date of request: Date the request is being made.
Hospital Information
2. Hospital name: Enter the legal name of the hospital requesting the services.
3. Provider number: Enter inpatient National Provider Identification (NPI) number.
4. Address: Enter the hospital’s address.
5. and 38. Contact person: Enter the name of the person who can be contacted regarding the request.
6. and 39. Contact person telephone number: Enter the phone number of the contact person.
7. Fax number: Enter the fax number of the hospital or contact person.
Client Information
8. and 36. Client name: Enter the client’s name, last, first, and middle.
9. Alias (AKA): Enter patient’s alias, if known.
10. Gender: Check the appropriate box.
11. Date of birth: Enter the client’s date of birth.
12. CCS/GHPP case number: Enter the client’s California Children’s Services (CCS)/Genetically Handicapped Persons (GHPP)
number. If number not known, leave blank.
13. Medical record number: Enter the patient’s hospital or office medical number.
14. Home phone number: Enter the home phone number where the client’s parent/legal guardian can be reached.
15. Cell phone number: Enter the cellular phone number where the client’s parent/legal guardian can be reached.
16. Work phone number: Enter the work phone number where the client’s parent/legal guardian can be reached.
17. Email address: Enter the email address of the client or client’s legal guardian.
18. Residence address: Enter the client’s address. Do not use a P.O. Box number.
19. Mailing address: Enter mailing address if different than 18.
20. County of residence: Residential county of the client.
21. Language spoken: Enter the client’s language spoken.
22. Name of parent/legal guardian: Enter the name of client’s parent/legal guardian.
23. Mother’s first name: Enter the client’s mother’s first name.
24. Primary care physician: Enter client’s primary care physician’s name; if it is not known, enter NK (not known).
25. Primary care physician telephone number: Enter client’s primary physician’s phone number.
Insurance Information
26. Enrolled in Medi-Cal? Check the appropriate box. If the answer is yes, enter the client’s index number in box 26.b. and the
client’s Medi-Cal number in box 26.c.
27. Enrolled in a commercial insurance plan? Check the appropriate box. If the answer is yes, check type of commercial
insurance plan and enter the name of the insurance plan on the line provided.
Diagnosis/Discharge Plan
28. Diagnosis: Enter the diagnosis, if known, relating to the requested services.
29. Plan to discharge: Check the appropriate box. If “transfer to” is checked, please specify where on line provided.
Specific Discharge Planning Services Requested
30., 31., 40., and 41. Provider’s name: Enter name of the provider who will be performing the services requested.
Provider number: Enter the provider’s provider number.
Telephone number: Enter phone number of the provider.
Contact person: Enter name of contact person at the provider’s office. Address: Enter
provider’s address.
Description of services: Describe service that is being requested.
EPSDT SS?: Check appropriate box. If yes, contact the State for prior authorization. Procedure code:
Enter the procedure code for the service being requested.
Units: For NDC, enter total number of fills plus refills. For all other codes enter the total number/amount of
services/supplies requested for SAR effective dates.
Quantity: Use only for products identified by NDC. For drugs, enter the amount to be dispensed (number, ml or cc, gms, etc.).
For lancets or test strips, enter the number per month or per dispensing period.
Additional information: Include a ny written details/instructions here.
Frequency/duration: Enter the frequency or duration of the procedures/services being requested.
Signature
32. and 42. Signature of discharge planner: Discharge planner signs here.
33. and 43. Title: Enter the title of person signing the document.
34. and 44. Name of discharging physician: Enter the name of the discharging physician.
35. and 45. Date: Enter the date signed.
DHCS 4489 (09/15) Page 3 of 3
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Dhcs4489 CCSGHPP Discharge Planning Service Authorization Request (SAR)

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Completed 3 July 2020

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