ESTABLISHED CCSGHPP CLIENT SERVICE AUTHORIZATION REQUEST (SAR) - dhcs ca 2026

1. Click ‘Get Form’ to open the ESTABLISHED CCSGHPP CLIENT SERVICE AUTHORIZATION REQUEST (SAR) in the editor.
2. Begin by filling out the Provider Information section. Enter the date of request, provider name, provider number, and address. Ensure you include a contact person along with their telephone and fax numbers.
3. Next, move to the Client Information section. Input the client's full name, gender, date of birth, CCS/GHPP case number, client index number (CIN), and Medi-Cal number as applicable.
4. In the Diagnosis section, enter any known diagnosis or ICD-10 codes related to the requested services.
5. Proceed to Requested Services. Specify whether this is a new SAR or an extension by checking the appropriate box and providing any necessary authorization numbers.
6. Fill in details for CPT-4/HCPCS codes and provide specific descriptions of services requested along with start and end dates.
7. Complete additional sections as needed for inpatient services or other healthcare providers before signing and dating the form at the end.

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