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The California DHS 4516 form is a crucial document for healthcare providers seeking authorization for dental and orthodontic services under the California Children’s Services (CCS) program. This form serves multiple purposes, primarily focusing on the authorization request for specific dental treatments for children who qualify for CCS. It captures essential provider information, including the provider’s name, contact details, and Denti-Cal provider number, ensuring that the request is directed to the appropriate individual. The client section of the form gathers vital information about the child, such as their name, date of birth, and insurance status, which is necessary for processing the request efficiently. Additionally, it includes sections for detailing the requested services, where providers specify the nature of the dental procedures, the relevant tooth numbers, and associated fees. This form also allows for supplemental service requests and the inclusion of any additional documentation that may support the authorization process. Accurate completion of the DHS 4516 is essential, as it certifies that the information provided is truthful and that the requested services are necessary for the patient's health. Timely submission of this form can significantly impact the speed at which services are authorized, making it imperative for providers to understand its components thoroughly.
Create Common PDFs
Dependent Care Credit Income Limit - Married couples filing jointly must also report their spouse's earned income on the form.
Court Notice - Both the judgment creditor's name and the judgment debtor's name are required.