Follow the steps to complete the form accurately.

1. Press the 'Get Form' button to access the New Referral CCS/GHPP Client Service Authorization Request (SAR). DHCS 4488. This will allow you to open the form in an editable format.
2. Fill in the provider information. Enter the date of request, provider name, provider number, address, contact person, contact telephone number, and contact fax number as accurately as possible.
3. Complete the client information section. Enter the client’s full name, alias if applicable, gender, date of birth, CCS/GHPP case number, medical record number, home phone, cell phone, work phone, email address, residence address, mailing address (if different), county of residence, language spoken, name of parent or legal guardian, mother’s first name, primary care physician name, and their telephone number.
4. In the insurance information section, indicate if the client is enrolled in Medi-Cal or a commercial insurance plan. Provide the necessary numbers and details about the insurance plan where required.
5. Describe the diagnosis using the DX/ICD-10 section for medical conditions relevant to the required services. Ensure the diagnosis is accurate and reflects the client's health status.
6. Fill out the requested services section. Include CPT-4/HCPCS codes or NDC for the services being requested, the specific description of the service or procedure, frequency/duration, and quantities needed to ensure the request is comprehensive.
7. For inpatient hospital services, provide the begin date, end date, and total number of days necessary for the stay. Ensure this information is precise to prevent delays.
8. If any services are to be referred to other healthcare providers, fill in their details, including the provider's name, telephone number, address, and description of the services requested.
9. Sign the document appropriately, ensuring the signature is from the physician, pharmacist, or authorized representative, along with the date of signing.
10. Once all sections are filled out, save changes, download, print, or share the form as needed to complete your submission accurately.

Complete your documents online today for efficient processing and service authorization.