NHSP Forms

Department of Health Care Services Forms

• Application to determine CCS Program Eligibility  English | Spanish  DHCS 4480 
  
• Communication Disorder Center Application  DHCS 4482
  
• New Referral CCS/GHPP Client SAR - NHSP Program Specific  DHCS 4488
  
• Outpatient Infant Hearing Screening Provider Application DHCS 4481 
  
• NHSP Early Start Referral Form
  

Newborn Hearing Screening Program (NHSP) Forms

• Brochure Forms 
  
• Military Consent for Release and Exchange of Information Form - NHSP 700-1 
  
• Diagnostic Audiologic Evaluation Reporting Form - NHSP 300-1 (Region Specific)
  To determine Region, please refer to the HCC Regional Map
• Region A/B
  
• Region C/D
  
• Infant Reporting Form - NHSP 100-1 (Region Specific)
• Region A/B
  
• Region C/D
  
• Outpatient Screening Reporting Form - NHSP 200-1 (Region Specific)
• Region A/B
  
• Region C/D
  
• Request Service Form has been updated to the: 
  New Referral CCS/GHPP Client SAR - NHSP Program Specific   DHCS 4488