Get Sc Dph Cc4c 2011-2025

Filling out the SC DPH CC4C form online is a straightforward process that helps ensure children receive the necessary care coordination services. This guide provides step-by-step instructions to help you complete the form accurately and efficiently.

Follow the steps to fill out the SC DPH CC4C form online.

1. Click ‘Get Form’ button to access the form and open it in the editor.
2. Begin by filling in the child’s name in the designated field. Next, enter the referral date using the format mm/dd/yyyy, followed by the child’s date of birth in the same format.
3. Select the gender of the child by choosing either 'Female' or 'Male'. Then, indicate the child's race from the available options.
4. Provide the Medicaid ID number, and select the appropriate status for insurance coverage: Uninsured, Health Choice, or Private Insurance. If you have applied for Medicaid, specify 'Yes' or 'No' and include the private insurance company name if applicable.
5. Complete the parent or guardian information section by filling in their name, date of birth, primary language spoken in the home, and whether they need an interpreter. Also, include their street address, P.O. Box (if applicable), city, zip code, county, and contact phone numbers.
6. Enter the employer's name and work phone number. Then, provide the name and contact number of a relative or neighbor who can be reached, in case further communication is needed.
7. In the referring medical home, agency, or organization section, fill out the referral organization name, contact person, their phone number, fax number, and email. Indicate if you are the child's primary care provider by checking the appropriate box.
8. Ensure the parent or guardian is informed of the referral by selecting 'Yes' or 'No'. If there is a medical provider involved, provide their practice name and phone number.
9. In the target populations for referrals section, check the relevant boxes based on the child’s circumstance and include specific concerns if applicable. If referring for developmental concerns, note if the child has been referred for Early Intervention Services.
10. If you, as the primary care provider, wish to make a direct referral for CC4C care management, check the box and provide a reason for the referral if it is not already indicated.
11. Review all completed fields for accuracy. Once done, you can save your changes, download a copy for your records, print the form, or share it with the appropriate parties.

Complete your SC DPH CC4C document online today to ensure timely and effective care for children.