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To apply, please print the following forms, fill them out, and mail them to your local health service office.
CSHCN Services Program Application (1857 KB, PDF) Publication #T-3
CSHCN Services Program Application in Spanish (550 KB, PDF) Publication #T-3A
CSHCN Services Program Physician/Dentist Assessment Form (PAF) (340 KB, PDF) Publication #T-4
Address Change Form
Address Change Form (483 KB PDF) / Formulario de cambio de domicilio Publication #EF07-12595, bilingual English and Spanish
Drug Co-Pay Reimbursement
Client Drug Co-Pay Reimbursement Request Form 2009 (47 KB Word) Publication #EF-07-13429, bilingual English and Spanish
Client Drug Co-Pay Reimbursement Request Form 2009 (96 KB PDF) Publication #EF-07-13429, bilingual English and Spanish
School Attendance Verification Form
School Attendance Verification Form (482 KB PDF) Publication #EF-07-12840, bilingual English and Spanish
Emergency Forms and Information
Medication Form Publication #EF07-12780, bilingual English and Spanish (PDF)
Emergency Information Form Publication #EF07-12540, bilingual English and Spanish (PDF)
Emergency Information Form Instructions (30 KB, Word)
Emergency and Disaster Planning Guide Publication #4-2, bilingual English and Spanish (PDF)
The CSHCN Services Program Client Handbook, Publication #E07-12357 (291 KB, PDF), provides basic information for program clients.
The CSHCN Services Program Newsletter for Families is published quarterly.
Download the brochure in English Stock No. 4-1 (474 KB, PDF). The file contains a copy of the brochure in color and black and white. Use the bookmarks to access either the color or black and white version.
Send comments or report broken links by e-mail to CSHCN Services Program.