Fill Your California Dhs 4516 Form

The California DHS 4516 form is a critical document used for requesting dental and orthodontic services under the California Children’s Services (CCS) program. Along with this form, several other documents may be necessary to ensure a complete and accurate service authorization request. Below is a list of additional forms that are commonly used in conjunction with the DHS 4516.

• Treatment Authorization Request (TAR): This form is used to obtain prior authorization for specific dental services that require approval before they can be billed. It ensures that the proposed treatments are covered under the patient’s insurance plan.
• Client Index Number (CIN) Verification: This document confirms the Client Index Number for individuals enrolled in Medi-Cal. It is essential for processing claims and verifying eligibility for services.
• Dental Record Release Form: This form allows the sharing of the patient’s dental records with the provider or other relevant parties. It ensures compliance with privacy regulations while facilitating necessary communication for treatment.
• Insurance Information Form: This document collects detailed insurance information from the client, including coverage specifics and policy numbers. It is crucial for determining the scope of services that can be authorized.

Completing these forms accurately and submitting them alongside the California DHS 4516 will help streamline the authorization process. It is vital to ensure that all information is up-to-date and correctly filled out to avoid delays in service provision.

Misconceptions about the California DHS 4516 form can lead to confusion among providers and clients. Here are four common misunderstandings:

• The form is only for orthodontic services. Many believe that the DHS 4516 form is exclusively for orthodontic requests. In reality, it is used for a variety of dental services under the California Children's Services program, including general dental care.
• Submitting the form guarantees service approval. Some assume that completing the form ensures that services will be authorized. However, submission does not guarantee approval. Each request is evaluated based on medical necessity and compliance with program guidelines.
• Only Medi-Cal enrolled clients can use this form. It is a common belief that only clients enrolled in Medi-Cal can submit the DHS 4516 form. In fact, the form can also be used by clients with other types of insurance, including Healthy Families and commercial dental plans.
• All information must be known before submission. Some think they must have every detail filled out before submitting the form. While complete information is ideal, it is acceptable to leave certain fields blank if the information is not known, such as the CCS case number or primary care physician.

How to Use California Dhs 4516

Completing the California DHS 4516 form is essential for requesting dental and orthodontic services for clients under the California Children’s Services program. Follow these steps to ensure all necessary information is accurately provided.

1. Date of request: Enter the date you are submitting the request.
2. Provider name: Fill in the name of the provider requesting the services.
3. Denti-Cal provider number: Enter the Denti-Cal billing number (do not include group numbers).
4. Address: Provide the complete address of the requesting provider.
5. Contact person: Enter the name of the person who can be contacted regarding this request.
6. Contact telephone number: Fill in the phone number for the contact person.
7. Contact fax number: Enter the fax number for the provider’s office or contact person.
8. Client name: Provide the client’s name in the format: last, first, and middle.
9. Gender: Check the appropriate box for male or female.
10. Date of birth: Enter the client’s date of birth in mm/dd/yy format.
11. CCS case number: Input the client’s CCS number. If unknown, leave this blank.
12. Contact phone number: Provide a phone number where the client or legal guardian can be reached.
13. Residence address: Enter the client’s residential address (do not use a P.O. Box).
14. Mailing address: If different from the residence address, provide the mailing address here.
15. County of residence: Enter the name of the county where the client resides.
16. Language spoken: Specify the language spoken by the client.
17. Name of parent/legal guardian: Fill in the name of the client’s parent or legal guardian.
18. Mother’s first name: Enter the first name of the client’s mother.
19. Primary care physician: Provide the name of the client’s primary care physician. If unknown, enter "NK".
20. Primary care physician telephone number: Enter the phone number for the primary care physician.
21. Enrolled in Medi-Cal? Check yes or no. If yes, do not send this form to CCS; send a TAR directly to Denti-Cal.
22. If no, Client Index Number (CIN): If not enrolled in Medi-Cal, enter the CIN.
23. Enrolled in Healthy Families? Check yes or no. If yes, enter the name of the plan.
24. Enrolled in commercial dental insurance plan? Check yes or no. If yes, provide the name of the plan.
25. Service Authorization Request for: Check either "CCS established client" or "CCS orthodontics".
26. Tooth Number or Description of Service: Enter the universal tooth code numbers or letters for the tooth being treated.
27. Tooth surfaces: Specify the surfaces using standard abbreviations.
28. Description of service: Provide a brief description for each service requested.
29. Quantity: Indicate the number of occurrences for the procedure.
30. Procedure numbers: Use the appropriate Denti-Cal codes for each service.
31. Fee: Enter your usual fee for the procedure.
32. CCS supplemental services request: Check yes or no.
33. Other documentation attached: Check yes if there are additional documents.
34. Comments: Provide any additional comments relevant to the request.
35. Signature of dental provider: The form must be signed by the dentist, orthodontist, or authorized representative.
36. Date: Enter the date the form is signed.