Fillable Integrated Systems of Care Division Service Authorization Request (Department of Health Care Services)

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Integrated Systems of Care Division Service Authorization Request (Department of Health Care Services)

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State of California
Health and Human Services Agency
Department of Health Care Services
Integrated Systems of Care Division
Service Authorization Request (SAR) Cover Sheet
Date : Phone Number:
From: Fax Number:
Client Name: Email:
Client CCS # : S AR #:
Client Date of Birth: S AR #:
CCS Physician Review Inbox
CCSPhysicianReview@dhcs.ca.gov
Right Fax: (916) 440-5308
Transplant Requests, including CAR-T: Yescarta, Kymriah
Cochlear Implant Surgery Requests
Out of State (OOS) Requests
CCS Expedited Review Inbox
CCSExpeditedReview@dhcs.ca.gov
Right Fax: (916) 440-5306
Bleeding Disorders: Blood Factor and Hemlibra
Cystic Fibrosis: Kalydeco, Orkambi, Symdeko, Trikafta
Duchenne Muscular Dystrophy: Eteplirsen, Golodirsen, Deflazacor t
Growth Disorders: Lupron, Histrelin, Triptorelin
High-Risk Infants: Synagis
Hospital Discharge Needs
Metabolic Diseases: Kuvan, Palynziq, Brineura, medical foods, enteral nutrition products
Retinal Disease: Luxturna
Seizure Management: Epidiolex
Spasticity Management: Botulinum Toxin
Spinal Muscular Atrophy: Spinraza, Zolgensma
Upcoming Surgery, including Selective Dorsal Rhizotomy
Other Expedited:
DHCS 4519 (10
/2020) Page 1 of 2
State of California
Health and Human Services Agency
Department of Health Care Services
Integrated Systems of Care Division
Se
rvice Authorization Request (SAR) Cover Sheet
CCS Directed Review Inbox
CCSDirectedReview@dhcs.ca.gov
Right Fax: (916) 440-5768
Annual Medical Review (AMR )
Diabetic Supplies, Pumps, Monitoring Devices
Durable Medical Equipment (DME)
Genetic Testing:
Routine Whole Genome
Whole Exome
Intercounty Transfer
Medical Eligibility Determination:
Whole Child Model Counties Medical Therapy Program
CMIPS III Counties
Neonatal Intensive Care Unit (NICU)
Off-label or Investigational Service
Previous Decision Reconsideration
Request for ISCD Physician Review
SARs submitted more than 45 days ago
Comme nts:
Other Directed:
This communication contains inf
ormation protected by the Health Insurance Portability and
Accountability Act of 1996 (HIPAA), and requires that you notify the sender above if you are not the
intended recipient as you are prohibited from reviewing, retaining, copying, or distributing this
information.
Submitting requested information is required to administer California Children’s Services (CSS),
unless stated otherwise. If not provided, services may be delayed or denied. Information may be
shared with other government agencies, contractors, health plans and providers to administer CCS.
Collection of this information is authorized by Welfare and Institutions Code section 123800, et seq.
For access to CCS records, contact CCS.
DHCS 4519 (10/2020) Page 2 of 2
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Integrated Systems of Care Division Service Authorization Request (Department of Health Care Services)

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Completed 7 February 2021

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