Get Established Ccsghpp Client Service Authorization Request (sar) - Dhcs Ca

The established CCSGHPP client service authorization request (SAR) is an essential document used for requesting services under the California Children’s Services and Genetically Handicapped Persons Program. This guide provides a step-by-step approach to completing the form online, ensuring clarity and ease of use for all users.

Follow the steps to accurately complete the form.

1. Click ‘Get Form’ button to access the established CCSGHPP client service authorization request (SAR) form.
2. Enter the date of the request in the appropriate field.
3. Provide the provider's name, billing number, and address, ensuring all details are accurate.
4. Fill in the contact person's name, telephone number, and fax number for any follow-up communications.
5. In the client information section, enter the client’s last name, first name, middle name, and check the appropriate gender box.
6. Input the client's date of birth, CCS/GHPP case number, client index number (CIN), and Medi-Cal number where applicable.
7. For diagnosis, enter the relevant diagnosis or ICD-10 codes in the designated field.
8. Indicate whether the request is for a new service authorization or an extension by checking the appropriate box and providing the existing authorization number if necessary.
9. In the requested services section, enter the CPT-4, HCPCS code, or NDC if required, followed by a specific description of the requested service.
10. Specify the start and end dates for the requested services, as well as their frequency and duration.
11. If applicable, check the box to indicate the attachment of additional documentation and provide the name of the facility where services are to be performed.
12. For inpatient hospital services, complete the begin and end dates, along with the number of days requested and any extension dates.
13. If you are requesting additional services from other healthcare providers, fill in their details, including name, number, telephone, and description of services.
14. Ensure the form is signed by the physician, pharmacist, or authorized representative and enter the date of signature.
15. Finally, you can save changes, download, print, or share the completed form as needed.

Complete your established CCSGHPP client service authorization request (SAR) online today!