CC4C Screening and Referral Form - Cabarrus Health 2026

1. Click ‘Get Form’ to open the CC4C Screening and Referral Form in our editor.
2. Begin by entering the child's name, referral date, and date of birth in the designated fields. Ensure accuracy as this information is crucial for processing.
3. Select the child's gender and race from the provided options. This helps in understanding demographic needs.
4. Fill in the Medicaid ID number or select the appropriate insurance status. If applicable, indicate if Medicaid has been applied for.
5. Complete the Parent/Guardian Information section, including names, contact details, and whether an interpreter is needed.
6. In the Target Populations for Referrals section, check any relevant boxes that apply to the child’s situation to ensure they receive appropriate services.
7. If making a direct referral from a medical home, check the corresponding box and specify reasons if necessary.
8. Review all entered information for accuracy before submitting. Once complete, submit the form to CMARC staff at your local health department.

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