Form Dhcs - California Children'S Services Maintenance And/or Transportation Authorization
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1State of California Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Maintenance and/or Transportation Authorization
Issue Date:
To:
(Name and Address)
CCS Client Name:
CCS Number:
Date of Birth:
California Children’s Services has authorized the following transportation and/or maintenance
services for the above client and/or responsible adult caregiver:
Lodging ____ Night(s) at a maximum cost of $__________ per night, at __________________.
Meals
Actual costs up to $15/day/person for ___ person(s).
Transportation
Mileage Reimbursement up to maximum cost of $______.
Mode of Travel: _____________ up to maximum cost of $______/person for ___ person(s).
Associated Costs (e.g., parking, tolls) actual cost up to $___________.
Services Authorized for the Period of ______________ to ______________.
Comments:
Additional prior authorization is needed for all additional expense requests.
Directions:
Receipts are required for all claimed expense (except for gasoline which is reimbursed
based on miles of needed travel).
For reimbursement, submit receipts for all costs along with a copy of this authorization.
Submit claim and receipts within ____ days of completed travel to:
(Local CCS Program Name and Address)
If you have questions, please call CCS at (
)
Failure to comply with these requirements may result in the client/caregiver being excluded
from future use of the CCS maintenance and transportation benefit.
CCS Staff Signature
DHCS (02/08)
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