Form Dhcs 4027 - California Children'S Services (Ccs) Consent For Medical Therapy Program Services

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State of California—Health and Human Services Agency
D epartment of Health Care Services
CCS Manual, Chapter 4, Attachment V
CALIFORNIA CHILDREN’S SERVICES (CCS)
CONSENT FOR MEDICAL THERAPY PROGRAM SERVICES
_________________________________________________________________________________________
Medical Therapy Unit
_________________________________________________________________________________________
County
I hereby authorize California Children’s Services to provide the medically necessary physical therapy and/or
occupational therapy services through the Medical Therapy Program for _____________________________.
Child’s Name
These services may include therapy evaluation, treatment, monitoring, instruction, consultation, and periodic
review by the Medical Therapy Conference team to assess the need for implementing, modifying, and/or
continuing services.
I understand that I have the right to appeal if I disagree with the CCS-approved therapy plan and that a copy of
the appeal process is attached to this form.
_______________________________________________________
__________________________________________________
_______________________
Signature of Parent, Caregiver, or Patient (if over 18 years of age)
Relationship to Patient
Date
_______________________________________________________
__________________________________________________
_______________________
Signature of CCS Representative
Print name of CCS Representative
Date
Original—File in CCS Case Record
Photocopy 1—File in Medical Therapy Unit Case Record
Photocopy 2—Parent copy
DHCS 4027 (06/07)

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