Get Sc Dph Cc4c 2017-2025

This guide provides clear instructions for completing the SC DPH CC4C referral form online. The form is designed to facilitate care coordination for children aged birth to five years who may have special health care needs.

Follow the steps to accurately complete the SC DPH CC4C form online.

1. Press the ‘Get Form’ button to access the SC DPH CC4C referral form and open it in your preferred digital format.
2. Begin filling out the form by entering the child's name, referral date, and date of birth in the appropriate fields. Ensure the dates are formatted as mm/dd/yyyy.
3. Select the child's gender by marking the appropriate box for either female or male.
4. Indicate the child's race by checking the relevant box from the options provided such as Asian, Black or African American, etc.
5. If applicable, provide the child's Medicaid ID number or check the appropriate box indicating the child's insurance status (uninsured, Health Choice, private insurance).
6. Indicate whether you have applied for Medicaid by selecting 'Yes' or 'No'.
7. If the child has private insurance, please enter the name of the insurance company in the designated field.
8. Fill in the parent or guardian's name and date of birth, followed by the primary language spoken at home.
9. If an interpreter is needed, select 'Yes' or 'No' accordingly.
10. Complete the address information by including the street address, city, zip code, and county.
11. Provide home and cell phone numbers, along with the employer's information and work phone if applicable.
12. List a relative or neighbor’s contact name and their phone number for additional communication.
13. Input referral organization details including contact person, phone number, email, and fax number as required.
14. Indicate whether the parent or guardian has been informed of the referral.
15. If applicable, provide the name of the child's primary care provider and their practice name along with their phone number.
16. Check any boxes under 'Target Populations for Referrals' that apply to the child to establish eligibility.
17. If applicable, specify the reason for referral in the designated space.
18. After completing the form, review all information for accuracy. Save your changes, and proceed to download, print, or share the form as needed.

Complete your SC DPH CC4C referral form online today to ensure timely care coordination.