Forms and Publications

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Children with Special Health Care Needs (CSHCN) Services Program logo

Forms

Program Application

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)  


Publications

Handbook

The CSHCN Services Program Client Handbook, Publication #E07-12357 (291 KB, PDF), provides basic information for program clients. 

Newsletter

The CSHCN Services Program Newsletter for Families is published quarterly.

Program Brochure

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.  



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Last updated November 29, 2016