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NHSP Forms
Department of Health Care Services Forms
Application to determine CCS Program Eligibility
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DHCS 4480
Communication Disorder Center Application
DHCS 4482
New Referral CCS/GHPP Client SAR - NHSP Program Specific
DHCS 4488
Outpatient Infant Hearing Screening Provider Application
DHCS 4481
NHSP Early Start Referral Form
Newborn Hearing Screening Program (NHSP) Forms
Brochure Forms
Military Consent for Release and Exchange of Information Form
- NHSP 700-1
Diagnostic Audiologic Evaluation Reporting Form - NHSP 300-1 (
Region Specific
)
To determine Region, please refer to the
HCC Regional Map
Region A/B
Region C/D
Infant Reporting Form - NHSP 100-1 (
Region Specific
)
Region A/B
Region C/D
Outpatient Screening Reporting Form - NHSP 200-1 (
Region Specific
)
Region A/B
Region C/D
Request Service Form has been updated to the:
New Referral CCS/GHPP Client SAR - NHSP Program Specific
DHCS 4488
Last modified date: 2/1/2023 9:25 AM
