Form Dhcs 4489 - California Ccs/ghpp Discharge Planning Service Authorization Request - Health And Human Services Agency Page 2

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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

Description of services

EPSDT SS?

Procedure code

Units

Quantity

Yes

Additional information

Frequency/duration

Provider’s name

41.

Telephone number

Contact person

Provider number

(

)

Address

City

State

ZIP code

Description of services

EPSDT SS?

Procedure code

Units

Quantity

Yes

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

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DHCS 4489 (09/15)