California Children's Services

Web Form DHCS 4480 PDF Application

This application is to be completed by the parent, legal guardian, or applicant (if age 18 or older, or an emancipated minor) in order to determine if the applicant is eligible for CCS services/benefits. The term "applicant" means the child, individual age 18 or older, or emancipated minor for whom the services are being requested. When the fields have been completed, please click the “Submit” button. Fields marked with a red asterisk ( * ) are required.**

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Application Instructions

Please fill out each section completely. If you do not provide all the information, CCS will not be able to proceed with your application. If you need help filling out this form, please contact the Sacramento County CCS office.

Sacramento County CCS
9616 Micron Avenue Suite 970
Sacramento, CA 95827
Business Hours: Monday – Friday, 8:00 AM – 5:00 PM
Telephone: (916) 875-9900
Once the application is completed, submit the application below.

Section A: Applicant Information
(”Applicant” means the child, individual age 18 or older, or emancipated minor for whom the services are being requested.)

1. Applicant’s name: Fill in the applicant’s last, first, and middle name. Then input the applicant’s full name as it appears on their birth certificate if different from their name. If theapplicant is known by any other name, include that name in the last box.

2. Applicant’s date of birth: Input the month, day, and year of the applicant’s birth.

3. Place of birth: Input the county and state where the applicant was born. Include the country ifthe applicant was born outside the U.S.

4. Address: Input the county and state where the applicant was born. Include the country ifthe applicant was born outside the U.S.

5. Applicant’s gender: Mark the correct sex box for the applicant (male or female).

6. Sexual Orientation and Gender Identity (Optional): If the applicant would like to tell us moreabout their gender, gender identity, gender expression or sexual orientation, please fill in items a,b, and c. Section 6 is optional, but is required for DHCS to ask with the passage of Assembly Bill 959 (2015 - 2016).

7. Race/Ethnicity: Please enter the category from the following list which best describes the applicant’s primary race/ethnicity:

Alaskan Native
Chinese
Laotian
Amerasian
Filipino
Samoan
American Indian
Guamanian
Vietnamese
Asian
Hawaiian
White
Asian Indian
Hispanic/Latino
Other
Black/African American
Japanese
Cambodian
Korean

8. Applicant’s social security number (optional): Input the applicant’s nine-digit socialsecurity number.

9. Suspected CCS condition or disability: Input the applicant’s disability or special health care need that would be treated by CCS. The enclosed description of CCS eligible conditions may help you. If you don’t know, ask the applicant’s doctor or leave the space blank. CCS will follow up with the applicant’s physician if more information is needed.

10. Name of applicant’s primary care physician: Input the name of the applicant’s physician.

11. Physician’s phone number: Input the phone number for the physician listed in number 16.

Section B:
Parent/Legal Guardian Information (Applicants age 18 or older, or emancipated minors skip items 12 and 14.)

12. Parent/guardian name(s): Input the name(s) of the applicant’s parent(s) or the name(s) of the applicant’s legal guardian(s).

13. Mother’s first name and maiden name: Input the applicant’s mother’s first name and maiden name.

14. Address: Input the street number, street name, apartment number, city, county, and ZIP code of your current residence. Please do not use a P.O. Box.

15. Mailing address: If this address is different from number 13, please input the street number, street name, city, and ZIP code.

16. Home phone number: Please input the home phone number where you can be reached.

17. Cell phone number:Please input the cell phone number where you can be reached.

18. Work phone number: Please input the work phone number where you can be reached.

19. Language(s) spoken: Input the language you speak at home.

20. Email address: Input the email address for the parent or legal guardian.

21. Number of persons in family unit: Input the number of persons living in the same household.

22. Other Parent Name and Address if not living with the applicant: Input the name and address for a second contact person.

Section C: Health Insurance Information
If CCS thinks you may qualify, they will ask you to apply for Medi-Cal if you are not currently receiving Medi-Cal health care benefits.

23. If the applicant does not receive Medi-Cal, check “No” and go to number 26a. If the applicant receives Medi-Cal, check “Yes” and fill in the applicant’s Medi-Cal number.

24. If you the applicant has Medi-Cal, enter the 14 digit Medi-Cal number.

25. If you pay a portion of the cost of your Medi-Cal insurance, check “Yes”.

26. If you pay a portion of the share of cost, fill in the monthly amount paid.

27a. If the applicant does not have other health insurance, check “No” and go to number 28.

27b. If the applicant has health insurance, fill in the name of the insurance plan or company.

27c. If the applicant has health insurance, fill in the policy or plan number.

28. If the applicant has health insurance, check the appropriate box depending upon what type of insurance it is. Your insurance forms will tell you what type of health insurance you have. If you are not sure, you can call your health insurance company and ask them.

29. If the applicant has dental insurance, check “Yes.” If the applicant does not have dental insurance, check “No.”

30. If the applicant has vision insurance, check “Yes.” If the applicant does not have vision insurance, check “No.”

Section D: Certification

Please input your name, the person’s name submitting the application. Under “Relationship to the applicant,” enter father, mother, legal guardian, or self (in the case of individuals age 18 or older, or emancipated minors).
Please input the date you are submitting the application

A. Applicant's Information

1. Name of Applicant

* Last Name

* First Name

Middle Name

Name on birth certificate (if different)

Any other name the applicant is known by

* 2. Date of Birth

3. Place of Birth

State

Country

* 4. Applicant's residence address (number, street) (do not use a P.O. Box)

* City

* County

* Zip Code

* 5. Sex Female Male

6. Sexual Orientation and Gender Identity (Optional):

If the applicant would like to tell us more about their gender, gender identity, gender expression or sexual orientation, please fill in items a, b, and c below. Section 6 is optional, but is required for DHCS to ask with the passage of Assembly Bill 959 (2015 - 2016).

a. What is the applicant’s gender (check the box that best describes your current gender identity)

Female

Male

Transgender: Male to Female

Transgender: Female to Male

Non-Binary (Neither Male nor Female)

Another Gender Identity

b. What sex was listed on the applicant's original birth certificate? Female Male

c. Does the applicant think of them self as:

Straight / Heterosexual

Gay / Lesbian

Bisexual

Queer

Another Sexual Orientation

Unknown

7. Race/Ethnicity

8. SSN (Optional)

9. What is the applicant's suspected eligible CCS condition or disability?

254 Character Maximum

10. Primary Care Physician

11. Physician Phone Number

B. Parent/Legal Guardian/Family Information
(Applicants age 18 or older, or emancipated minors skip items 11 and 13.)

12. Parent/guardian name(s)

* 13. Mother's First name

* Maiden name

14. Residence street address (do not use a P.O. Box)

City

County

Zip Code

15. Mailing Street Address (if different from 14)

City

County

Zip Code

* 16. Home phone number

17. Cell phone number

18. Work phone number

19. Language spoken at home

20. Email address

21. Number of persons in family unit

22. Other Parent Name and Address if not living with the applicant

C. Health Insurance Information

23. Does the applicant have Medi-Cal Yes No

24. If yes, what is applicant's Medi-Cal Number

25. Is there a share-of-cost Yes No

26. If Yes, what is the amount you pay per month?

27a. Does the applicant have other Health Insurance Yes No

27b. If yes, what is the name of the insurance plan or company?

27c. Policy or Plan Number

28. Type of Insurance Plan or Company With Check Box For the Following Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
Other
Specify:

29. Dental Coverage Yes No

30. Vision Coverage Yes No

D. Certification (Initial and submit below. Your submission of this electronic form authorizes the CCS program to proceed with this application.)

I am applying to the CCS program in order to determine eligibility for services/benefits. I understand that the completion of this application does not assure acceptance of applicant by the CCS program.

I give my permission to verify my residence, health information, or other circumstances required to determine eligibility for CCS services / benefits.

I certify that I have read and understand the information or have had it read to me.

I also certify that the information I have given on this form is true and correct.

* Signature of person completing the application

* Relationship to the applicant

* Date

Signature of witness (only if the person signed with a mark)

Date

Web Form DHCS 4480 PDF Application

A. Applicant's Information

B. Parent/Legal Guardian/Family Information (Applicants age 18 or older, or emancipated minors skip items 11 and 13.)

C. Health Insurance Information

D. Certification (Initial and submit below. Your submission of this electronic form authorizes the CCS program to proceed with this application.)

B. Parent/Legal Guardian/Family Information
(Applicants age 18 or older, or emancipated minors skip items 11 and 13.)