California Form Dhs 4516 PDF Details

In the vast ecosystem of healthcare and dental care forms, the California DHS 4516 form emerges as a pivotal document, designed specifically for the California Children’s Services (CCS). This form serves as the Dental and Orthodontic Client Service Authorization Request (SAR), a critical step for providers seeking approval to deliver essential dental and orthodontic services to CCS clients. It meticulously gathers provider information, including details such as the request date, provider name, Denti-Cal provider number, and contact information, ensuring an organized channel of communication between healthcare providers and the CCS program. The form also captures comprehensive client information, from the basics such as name, gender, and date of birth to more detailed data including CCS case number, insurance enrollment status, and the specific services being requested. For services, the form allows providers to specify whether the request is for a CCS established client or for orthodontic services, alongside details about the specific dental work required. This meticulous attention to detail underscores the form’s role not only as a tool for request submission but also as a document ensuring that the right services are authorized for the right individuals, thereby facilitating the delivery of specialized dental care to children and youth in California who qualify for CCS benefits.

QuestionAnswer
Form NameCalifornia Form Dhs 4516
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesSARDentalOrthod ontia ccs dental and orthodontic client service authorization request form

Form Preview Example

State of California—Health and Human Services Agency

 

 

 

 

 

 

 

Department of Health Services

 

 

 

 

 

 

 

 

 

 

 

 

 

California Children’s Services (CCS)

 

CCS DENTAL AND ORTHODONTIC CLIENT SERVICE AUTHORIZATION REQUEST (SAR)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider Information

 

 

 

 

 

 

1.

Date of request

 

2. Provider name

 

 

 

 

3.

Denti-Cal provider number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Address (number, street)

 

 

 

 

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Contact person

 

 

 

6.

Contact telephone number

7. Contact fax number

 

 

 

 

 

 

 

 

(

)

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Client Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Client name—last

 

 

 

first

 

 

 

middle

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Gender

 

 

10. Date of birth (mm/dd/yy)

 

11. CCS case number

 

 

 

12. Contact phone number

 

Male

Female

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Residence address (number, street) (DO NOT USE P.O. BOX)

 

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

14.

Mailing address (if different) (number, street, P.O. box number)

 

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

15.

County of residence

 

16.

Language spoken

17. Name of parent/legal guardian

 

 

 

 

 

 

18.

Mother’s first name

 

19.

Primary care physician (if known)

20. Primary care physician telephone number

 

 

 

 

 

 

 

 

 

(

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Insurance Information

21. a. Enrolled in Medi-Cal?

Yes

No

If yes, send TAR directly to Denti-Cal

21. b. If no, Client Index Number (CIN)

22.

Enrolled in Healthy Families?

If yes, name of plan

 

 

Yes

No

 

 

 

 

 

 

23.

Enrolled in commercial dental insurance plan?

If yes, name of plan

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Requested Services

 

 

 

 

 

24.

Service Authorization Request for (CHECK ONE)

 

 

a. CCS established client

b. CCS orthodontics

25.

26.

27.

28.

29.

30.

 

 

 

 

 

 

Tooth Number or

 

Description of Service

 

Procedure

 

Letter Arch

Surfaces

(Including X-rays, prophylaxis, etc.)

Quantity

Number

Fee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

31. Is this a CCS supplemental services request

Yes

No

32.Other documentation attached

Yes

33. Comments

This is to certify that to the best of my knowledge, the information contained above and any attachments provided is true, accurate, and complete and the requested services are necessary to the health of the patient. The provider has read, understands, and agrees to be bound by and comply with the statements and conditions contained on page two of this form.

34. Signature of dental provider or authorized designee

35. Date

DHS 4516 (7/04)

Page 1 of 2

Instructions

1.Date of the request: Date the request is being made.

Provider Information

2.Provider’s name: Enter the name of the provider who is requesting services.

3.Denti-Cal provider number: Enter Denti-Cal billing number (no group numbers).

4.Address: Enter the requesting provider’s address.

5.Contact person: Enter the name of the person who can be contacted regarding the request; all authorizations should be addressed to the contact person.

6.Contact telephone number: Enter the phone number of the contact person.

7.Contact fax number: Enter the fax number for the provider’s office or contact person.

Client Information

8.Client name: Enter the client’s name—last, first, and middle.

9.Gender: Check the appropriate box.

10.Date of birth: Enter the client’s date of birth.

11.CCS case number: Enter the client’s CCS number. If not known, leave blank.

12.Contact phone number: Enter the phone number where the client or client’s legal guardian can be reached.

13.Residence address: Enter the address of the client. Do not use a P.O. Box number.

14.Mailing address: Enter the mailing address if it is different than number 13.

15.County of residence: Enter residential county of the client.

16.Language spoken: Enter the client’s language spoken.

17.Name of parent/legal guardian: Enter the name of client’s parent/legal guardian.

18.Mother’s first name: Enter the client’s mother’s first name.

19.Primary care physician: Enter the client’s primary care physician’s name. If it is not known, enter NK (not known).

20.Primary care physician telephone number: Enter the client’s primary care physician phone number.

Insurance Information

21.a. Enrolled in Medi-Cal? Mark the appropriate box. If the answer is yes, do not send this SAR to CCS, send a TAR directly to Denti-Cal.

b. If the answer is no, enter the Client Index Number (CIN).

22.Enrolled in Healthy Families? Mark the appropriate box. If the answer is yes, enter the name of the plan.

23.Enrolled in a commercial dental insurance plan? Mark the appropriate box. If the answer is yes, enter the name of the commercial dental insurance plan.

Requested Services

24.a. CCS established client: Check if requesting approval for an established CCS client.

b. CCS Orthodontics: Check if requesting approval for orthodontic services.

25.Tooth number or letter; arch; quadrant: Enter the universal tooth code numbers 1 thru 32 or letters A thru T for tooth reference. Use arch codes U (upper), L (lower). Use quadrant codes UR (upper right), UL (upper left), LR (lower right), and LL (lower left).

26.Tooth surfaces: Use M (mesial), D (distal), O (occlusal), I (incisal), L (lingual or palatal), B (buccal), and F (facial).

27.Description of service: Furnish a brief description for each service. Standard abbreviations are acceptable.

28.Quantity: For the procedures having multiple occurrences, indicate the number of occurrences of the procedure, e.g., multiple radiographs (procedure 111), units for prosthetic procedures (procedure 716), or number of pins (procedure 648).

29.Procedure numbers: Use a Denti-Cal three-digit, state-approved four-digit, or state-approved five-digit code for each service.

NOTE: Do not mix different types of codes when completing a claim or TAR form.

30.Fee: Enter your usual and customary fee for the procedure rather than the Denti-Cal Schedule of Maximum Allowances fee.

31.Check yes or no box if this is a CCS Supplemental Services Request.

32.Check the box if there is other documentation attached.

33.Comments. Enter any additional comments.

Signature

34.Signature of dental provider: Form must be signed by the dentist, orthodontist, or authorized representative.

35.Date: Enter the date the request is signed.

DHS 4516 (7/04)

Page 2 of 2

How to Edit California Form Dhs 4516 Online for Free

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This PDF doc requires some specific details; in order to guarantee correctness, please make sure to pay attention to the tips further on:

1. Before anything else, while completing the California Form Dhs 4516, begin with the part that features the next blanks:

California Form Dhs 4516 conclusion process described (part 1)

2. After this part is done, go on to type in the suitable information in all these - Service Authorization Request for, a CCS established client, b CCS orthodontics, Requested Services, Tooth Number or, Letter Arch, Surfaces, Description of Service, Including Xrays prophylaxis etc, Quantity, Procedure, Number, Fee, Is this a CCS supplemental, and Other documentation attached.

Tips to prepare California Form Dhs 4516 portion 2

Regarding Procedure and Other documentation attached, make sure you double-check them here. Both these are considered the most important ones in this page.

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