Form Dhcs 4489 - California Ccs/ghpp Discharge Planning Service Authorization Request - Health And Human Services Agency

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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
7. Fax number
(
)
(
)
Client Information
8. Client name—last
first
middle
9. Alias (AKA)
10. Gender
11. Date of birth (mm/dd/yyyy)
Male
Female
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.c. Client’s Medi-Cal number
26.a. Enrolled in Medi-Cal?
26.b. If yes, client index number (CIN)
Yes
No
27. Enrolled in commercial insurance plan?
If yes, type of commercial insurance plan
Name of plan
Yes
No
PPO
HMO
Other
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
Description of services
EPSDT SS?
Quantity
Procedure code
Units
Yes
No
Additional information
Frequency/duration
31. Provider’s name
Provider number
Telephone number
Contact person
(
)
Address
City
State
ZIP code
Description of services
EPSDT SS?
Procedure code
Units
Quantity
Yes
No
Additional information
Frequency/duration
32. Signature of discharge planner
33. Title
34. Name of discharging physician
35. Date
Page 1 of 3
DHCS 4489 (09/15)

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