Fillable Mc2142 California Children's Services Face Sheet

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Mc2142 California Children's Services Face Sheet

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State of California—Health and Human Services Agency Department of Health Care Services
Children’s Medical Services Branch
CALIFORNIA CHILDREN’S SERVICES FACE SHEET
County of residence Birthplace (county, other state, or country) Medi-Cal number (attach copy of card if available) Effective date California Children’s Services number
Legal name (last, first, middle) Nickname Social Security number Birth date (month, day, year) Sex
U
Male
U
Female
– U Unknown
Address (number, street) City ZIP code Telephone Cross street or landmark
(
Mother Maiden name Social Security number Birth date (month, day, year)
–
Address (number, street)
City ZIP code Telephone
(
Employer Address (number, street) City ZIP code Telephone
(
Health insurance company Address (number, street) City ZIP code Policy/group number
Father Social Security number Birth date (month, day, year)
–
Address (number, street) City ZIP code Telephone
(
Employer Address (number, street) City ZIP code Telephone
(
Health insurance company Address (number, street) City ZIP code Policy/group number
Legal guardian Address (number, street) City ZIP code Telephone
(
Foster parent/relationship Address (number, street) City ZIP code Telephone
(
School Grade Telephone Nurse
(
Address (number, street) City ZIP code
Physician Telephone Send reports
( U Yes U No
Address (number, street) City ZIP code
Specialist requested Specialty City Telephone
(
Specialist requested Specialty City Telephone
(
–
)
–
)
)
–
)
)
)
)
)
)
)
)
Reason for referral: Describe nature of physical handicap, significant associated conditions, dates of onset, date/types of treatment, and where care was received.
Factors that will assist CCS in planning care, e.g., transportation, language, social, housing, Others in home (check CCS patients)
other agencies involved, previous CCS coverage
CCS? Name Birth Year Relationship to Patient
U
U
Presumptive CCS eligible diagnosis (CCS Use Only) U
U
Race: Referral source:
U White U Hispanic/Latino U Filipino U Asian U American-Indian U Parent U Physician U CCS case finding U Other provider U CHDP—EPSDT
U Black U Other nonwhite U No response U Unknown U School U Hospital U DD regional center U Other _______________________
Referred by: Title Agency Telephone Date
(
Face sheet completed by: Title Agency Telephone Date
(
Name
)
Name
)
MC 2142 (09/07)
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Mc2142 California Children's Services Face Sheet

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Completed 3 July 2020

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