Form Dhcs 4489 - California Ccs/ghpp Discharge Planning Service Authorization Request - Health And Human Services Agency Page 3

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INSTRUCTIONS
1.
and 35.
Date of request: Date the request is being made.
Hospital Information
2.
Hospital name: Enter the legal name of the hospital requesting the services.
3.
Provider number: Enter inpatient National Provider Identification (NPI) number.
Address: Enter the hospital’s address.
4.
5.
and 38.
Contact person: Enter the name of the person who can be contacted regarding the request.
6.
and 39.
Contact person telephone number: Enter the phone number of the contact person.
7.
Fax number: Enter the fax number of the hospital or contact person.
Client Information
Client name: Enter the client’s name, last, first, and middle.
8.
and 36.
Alias (AKA): Enter patient’s alias, if known.
9.
10.
Gender: Check the appropriate box.
Date of birth: Enter the client’s date of birth.
11.
CCS/GHPP case number: Enter the client’s California Children’s Services (CCS)/Genetically Handicapped Persons (GHPP)
12.
number. If number not known, leave blank.
Medical record number: Enter the patient’s hospital or office medical number.
13.
Home phone number: Enter the home phone number where the client’s parent/legal guardian can be reached.
14.
Cell phone number: Enter the cellular phone number where the client’s parent/legal guardian can be reached.
15.
Work phone number: Enter the work phone number where the client’s parent/legal guardian can be reached.
16.
Email address: Enter the email address of the client or client’s legal guardian.
17.
Residence address: Enter the client’s address. Do not use a P.O. Box number.
18.
19.
Mailing address: Enter mailing address if different than 18.
20.
County of residence: Residential county of the client.
Language spoken: Enter the client’s language spoken.
21.
Name of parent/legal guardian: Enter the name of client’s parent/legal guardian.
22.
Mother’s first name: Enter the client’s mother’s first name.
23.
Primary care physician: Enter client’s primary care physician’s name; if it is not known, enter NK (not known).
24.
Primary care physician telephone number: Enter client’s primary physician’s phone number.
25.
Insurance Information
Enrolled in Medi-Cal? Check the appropriate box. If the answer is yes, enter the client’s index number in box 26.b. and the
26.
client’s Medi-Cal number in box 26.c.
27.
Enrolled in a commercial insurance plan? Check the appropriate box. If the answer is yes, check type of commercial
insurance plan and enter the name of the insurance plan on the line provided.
Diagnosis/Discharge Plan
28.
Diagnosis: Enter the diagnosis, if known, relating to the requested services.
Plan to discharge: Check the appropriate box. If “transfer to” is checked, please specify where on line provided.
29.
Specific Discharge Planning Services Requested
Provider’s name: Enter name of the provider who will be performing the services requested.
30., 31., 40., and 41.
Provider number: Enter the provider’s provider number.
Telephone number: Enter phone number of the provider.
Contact person: Enter name of contact person at the provider’s office. Address: Enter
provider’s address.
Description of services: Describe service that is being requested.
EPSDT SS?: Check appropriate box. If yes, contact the State for prior authorization. Procedure code:
Enter the procedure code for the service being requested.
Units: For NDC, enter total number of fills plus refills. For all other codes enter the total number/amount of
services/supplies requested for SAR effective dates.
Quantity: Use only for products identified by NDC. For drugs, enter the amount to be dispensed (number, ml or cc, gms, etc.).
For lancets or test strips, enter the number per month or per dispensing period.
Additional information: Include a ny written details/instructions here.
Frequency/duration: Enter the frequency or duration of the procedures/services being requested.
Signature
32. and 42.
Signature of discharge planner: Discharge planner signs here.
33. and 43.
Title: Enter the title of person signing the document.
34. and 44.
Name of discharging physician: Enter the name of the discharging physician.
35. and 45.
Date: Enter the date signed.
Page 3 of 3
DHCS 4489 (09/15)

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