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Outline

The California DHS 4516 form plays a crucial role in facilitating dental and orthodontic services for children enrolled in the California Children’s Services (CCS) program. This form is essential for providers seeking authorization for specific dental procedures, ensuring that necessary services are delivered to eligible clients. It includes sections for provider information, client details, insurance status, and a comprehensive list of requested services. Providers must fill out their contact information, the client's personal details, and any relevant insurance information, such as Medi-Cal or Healthy Families enrollment. Additionally, the form requires a detailed description of the requested services, including procedure codes, tooth numbers, and associated fees. The completion of this form not only verifies the necessity of the requested services but also certifies that the information provided is accurate and complete. By adhering to the guidelines outlined in the form, providers can help ensure that children receive the dental care they need in a timely manner.

Sample - California Dhs 4516 Form

State of California—Health and Human Services Agency Department of Health Services
California Children’s Services (CCS)
CCS DENTAL AND ORTHODONTIC CLIENT SERVICE AUTHORIZATION REQUEST (SAR)
Provider Information
1. Date of request 2. Provider name 3. Denti-Cal provider number
4. Address (number, street) City State ZIP code
5. Contact person 6. Contact telephone number 7. Contact fax number
( ) ( )
Client Information
8. Client name—last first middle
9. Gender 10. Date of birth (mm/dd/yy) 11. CCS case number 12. Contact phone number
Male
Female ( )
13. Residence address (number, street) (DO NOT USE P.O. BOX) City State ZIP code
14. Mailing address (if different) (number, street, P.O. box number) City State ZIP code
15. County of residence 16. Language spoken 17. Name of parent/legal guardian
18. Mother’s first name 19. Primary care physician (if known) 20. Primary care physician telephone number
( )
Insurance Information
21. a. Enrolled in Medi-Cal?
Yes No If yes, send TAR directly to Denti-Cal
21. b. If no, Client Index Number (CIN)
22. Enrolled in Healthy Families?
Yes No
If yes, name of plan
23. Enrolled in commercial dental insurance plan?
Yes No
If yes, name of plan
Requested Services
24. Service Authorization Request for (check one)
a. CCS established client b. CCS orthodontics
25. 26. 29. 30.
Tooth Number or
Letter Arch Surfaces
Description of Service
(Including X-rays, prophylaxis, etc.) Quantity
Procedure
Number
28. 27.
Fee
31. Is this a CCS supplemental services request
Yes No
32. Other documentation attached
Yes
33. Comments
This is to certify that to the best of my knowledge, the information contained above and any attachments provided is true, accurate, and
complete and the requested services are necessary to the health of the patient. The provider has read, understands, and agrees to be
bound by and comply with the statements and conditions contained on page two of this form.
34. Signature of dental provider or authorized designee 35. Date
DHS 4516 (7/04) Page 1 of 2
Instructions
1. Date of the request: Date the request is being made.
Provider Information
2. Provider’s name: Enter the name of the provider who is requesting services.
3. Denti-Cal provider number: Enter Denti-Cal billing number (no group numbers).
4. Address: Enter the requesting provider’s address.
5. Contact person: Enter the name of the person who can be contacted regarding the request; all authorizations should be addressed to
the contact person.
6. Contact telephone number: Enter the phone number of the contact person.
7. Contact fax number: Enter the fax number for the provider’s office or contact person.
Client Information
8. Client name: Enter the client’s name—last, first, and middle.
9. Gender: Check the appropriate box.
10. Date of birth: Enter the client’s date of birth.
11. CCS case number: Enter the client’s CCS number. If not known, leave blank.
12. Contact phone number: Enter the phone number where the client or client’s legal guardian can be reached.
13. Residence address: Enter the address of the client. Do not use a P.O. Box number.
14. Mailing address: Enter the mailing address if it is different than number 13.
15. County of residence: Enter residential county of the client.
16. Language spoken: Enter the client’s language spoken.
17. Name of parent/legal guardian: Enter the name of client’s parent/legal guardian.
18. Mother’s first name: Enter the client’s mother’s first name.
19. Primary care physician: Enter the client’s primary care physician’s name. If it is not known, enter NK (not known).
20. Primary care physician telephone number: Enter the client’s primary care physician phone number.
Insurance Information
21. a. Enrolled in Medi-Cal? Mark the appropriate box. If the answer is yes, do not send this SAR to CCS, send a TAR directly to
Denti-Cal.
b. If the answer is no, enter the Client Index Number (CIN).
22. Enrolled in Healthy Families? Mark the appropriate box. If the answer is yes, enter the name of the plan.
23. Enrolled in a commercial dental insurance plan? Mark the appropriate box. If the answer is yes, enter the name of the commercial
dental insurance plan.
Requested Services
24. a. CCS established client: Check if requesting approval for an established CCS client.
b. CCS Orthodontics: Check if requesting approval for orthodontic services.
25. Tooth number or letter; arch; quadrant: Enter the universal tooth code numbers 1 thru 32 or letters A thru T for tooth reference. Use
arch codes U (upper), L (lower). Use quadrant codes UR (upper right), UL (upper left), LR (lower right), and LL (lower left).
26. Tooth surfaces: Use M (mesial), D (distal), O (occlusal), I (incisal), L (lingual or palatal), B (buccal), and F (facial).
27. Description of service: Furnish a brief description for each service. Standard abbreviations are acceptable.
28. Quantity: For the procedures having multiple occurrences, indicate the number of occurrences of the procedure, e.g., multiple
radiographs (procedure 111), units for prosthetic procedures (procedure 716), or number of pins (procedure 648).
29. Procedure numbers: Use a Denti-Cal three-digit, state-approved four-digit, or state-approved five-digit code for each service.
NOTE: Do not mix different types of codes when completing a claim or TAR form.
30. Fee: Enter your usual and customary fee for the procedure rather than the Denti-Cal Schedule of Maximum Allowances fee.
31. Check yes or no box if this is a CCS Supplemental Services Request.
32. Check the box if there is other documentation attached.
33. Comments. Enter any additional comments.
Signature
34. Signature of dental provider: Form must be signed by the dentist, orthodontist, or authorized representative.
35. Date: Enter the date the request is signed.
DHS 4516 (7/04) Page 2 of 2
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Form Information

Fact Name Description
Purpose The DHS 4516 form is used to request service authorization for dental and orthodontic services for clients under California Children's Services (CCS).
Client Information The form requires detailed client information, including name, date of birth, and residence address. This helps ensure that services are provided to the correct individual.
Insurance Details Providers must indicate whether the client is enrolled in Medi-Cal or other insurance plans. This information is crucial for processing the request.
Governing Law This form is governed by California Welfare and Institutions Code, Section 14000 et seq., which outlines the provisions for California Children's Services.
Signature Requirement The form must be signed by the dental provider or an authorized designee, certifying that the information provided is accurate and complete.

Detailed Guide for Filling Out California Dhs 4516

Completing the California DHS 4516 form requires careful attention to detail. Each section must be filled out accurately to ensure the request is processed smoothly. Follow the steps below to fill out the form correctly.

  1. Date of request: Enter the date when the request is being made.
  2. Provider name: Fill in the name of the provider requesting services.
  3. Denti-Cal provider number: Input the Denti-Cal billing number, avoiding group numbers.
  4. Address: Provide the complete address of the requesting provider.
  5. Contact person: Write the name of the person to contact regarding the request.
  6. Contact telephone number: Enter the phone number for the contact person.
  7. Contact fax number: Fill in the fax number for the provider's office or contact person.
  8. Client name: Enter the client's full name (last, first, middle).
  9. Gender: Check the appropriate box for the client's gender.
  10. Date of birth: Input the client’s date of birth in mm/dd/yy format.
  11. CCS case number: Enter the client’s CCS case number, if known; leave blank if not.
  12. Contact phone number: Provide a phone number for the client or their legal guardian.
  13. Residence address: Enter the client’s residential address (no P.O. Box).
  14. Mailing address: If different from the residence address, provide the mailing address.
  15. County of residence: Indicate the client’s county of residence.
  16. Language spoken: Enter the language the client speaks.
  17. Name of parent/legal guardian: Provide the name of the client’s parent or legal guardian.
  18. Mother’s first name: Enter the first name of the client’s mother.
  19. Primary care physician: Input the name of the primary care physician, or write NK if unknown.
  20. Primary care physician telephone number: Enter the phone number for the primary care physician.
  21. Enrolled in Medi-Cal? Mark yes or no. If yes, do not send this SAR to CCS; send a TAR to Denti-Cal instead.
  22. If no, Client Index Number (CIN): Provide the CIN if the client is not enrolled in Medi-Cal.
  23. Enrolled in Healthy Families? Mark yes or no, and if yes, include the name of the plan.
  24. Enrolled in commercial dental insurance plan? Mark yes or no, and if yes, provide the name of the plan.
  25. Service Authorization Request for: Check either the CCS established client or CCS orthodontics box.
  26. Tooth Number or Description of Service: Enter the tooth number or description of the service being requested.
  27. Tooth surfaces: Use appropriate letters to indicate tooth surfaces.
  28. Quantity: Indicate the number of occurrences for the procedure.
  29. Procedure numbers: Use the correct Denti-Cal code for each service.
  30. Fee: Enter the usual and customary fee for the procedure.
  31. CCS supplemental services request: Check yes or no as applicable.
  32. Other documentation attached: Check the box if additional documentation is included.
  33. Comments: Provide any additional comments relevant to the request.
  34. Signature of dental provider: The form must be signed by the dentist, orthodontist, or authorized representative.
  35. Date: Enter the date when the request is signed.

Obtain Answers on California Dhs 4516

  1. What is the purpose of the California DHS 4516 form?

    The California DHS 4516 form, also known as the CCS Dental and Orthodontic Client Service Authorization Request (SAR), is used to request authorization for dental and orthodontic services for clients enrolled in California Children's Services (CCS). This form ensures that necessary services are approved before they are provided, which helps in managing costs and ensuring that clients receive appropriate care.

  2. Who needs to fill out the DHS 4516 form?

    The form must be completed by the dental provider or an authorized representative requesting services for a client. It requires detailed information about both the provider and the client, including personal details and insurance information. Accuracy is crucial, as the information provided will determine the approval of the requested services.

  3. What information is required on the form?

    The form requires several key pieces of information:

    • Provider details, including name, Denti-Cal provider number, and contact information.
    • Client information, such as name, date of birth, CCS case number, and residence address.
    • Insurance information, indicating whether the client is enrolled in Medi-Cal, Healthy Families, or any commercial dental insurance.
    • Details about the requested services, including specific procedures, tooth numbers, and fees.

    Each section must be filled out completely to avoid delays in processing.

  4. What happens after the form is submitted?

    Once the DHS 4516 form is submitted, it will be reviewed by the appropriate authority. If the requested services are approved, the provider will receive authorization to proceed with the treatment. If there are any issues or if additional information is needed, the provider may be contacted for clarification. It’s important to keep a copy of the submitted form for your records.

Common mistakes

Filling out the California DHS 4516 form can be a straightforward process, but many people make common mistakes that can delay their requests. One frequent error is failing to provide the correct Denti-Cal provider number. This number is essential for processing the request, and any inaccuracies can lead to unnecessary delays.

Another common mistake is using a P.O. Box for the residence address. The form specifically instructs not to use P.O. Box numbers, yet many individuals overlook this requirement. Providing a physical address is crucial for accurate communication and service delivery.

Many people also forget to include the client’s date of birth in the correct format. The form requires the date to be entered as mm/dd/yy. Incorrect formatting can cause confusion and may result in the request being rejected.

In the insurance information section, some individuals mistakenly mark the wrong boxes regarding Medi-Cal enrollment. It’s important to carefully review the options. If the client is enrolled in Medi-Cal, the request should not be sent to CCS but directly to Denti-Cal.

Another frequent oversight is leaving out the CCS case number. If this number is unknown, it should be left blank rather than filled in incorrectly. An incorrect case number can lead to complications in processing the request.

When detailing the requested services, individuals often neglect to provide specific tooth numbers or descriptions. It’s vital to use the universal tooth code numbers or letters and include any necessary details about the services being requested. This information is key to ensuring that the right services are authorized.

Some applicants also fail to check the box indicating whether the request is for CCS supplemental services. This can lead to confusion about the nature of the request and may cause delays in approval.

Another mistake is not including a contact phone number for the client or legal guardian. This number is crucial for follow-up communications, and omitting it can hinder the process.

Lastly, individuals sometimes forget to sign the form or include the date of signature. The form must be signed by the dental provider or an authorized representative to be valid. Without a signature, the request cannot be processed.

By being aware of these common mistakes and taking the time to double-check the form, individuals can help ensure a smoother and more efficient submission process.

Documents used along the form

The California DHS 4516 form is a critical document used to request authorization for dental and orthodontic services for clients under the California Children's Services (CCS) program. Several other forms and documents often accompany this request, each serving a specific purpose in the authorization process. Below is a list of these documents.

  • CCS Treatment Authorization Request (TAR): This form is used to obtain prior approval for specific medical services covered under the CCS program. It details the proposed treatment and justifies its necessity based on the client’s medical condition.
  • Client Index Number (CIN) Documentation: This document provides the unique identification number assigned to clients enrolled in Medi-Cal. It is essential for tracking and managing the client’s services and claims.
  • Insurance Verification Form: This form confirms the client's dental insurance coverage, including any commercial plans or Medi-Cal enrollment. It helps providers understand the scope of benefits available to the client.
  • Referral Form: A referral from the primary care physician may be required, indicating that the client needs dental or orthodontic services. This form ensures that the treatment aligns with the client’s overall health plan.
  • Consent for Treatment Form: This document must be signed by the client’s parent or legal guardian, granting permission for the proposed dental or orthodontic procedures. It ensures that the provider has the necessary consent to proceed with treatment.
  • Clinical Notes or Medical Records: These documents provide background information on the client’s dental health, including previous treatments and current conditions. They support the need for the requested services and assist in the decision-making process.

Each of these documents plays a vital role in ensuring that the authorization process for dental and orthodontic services runs smoothly. Properly completing and submitting them can help facilitate timely access to necessary care for clients enrolled in the CCS program.

Similar forms

  • California Medi-Cal Service Authorization Request (SAR): Like the DHS 4516 form, this document is used to request authorization for medical services under the Medi-Cal program. It requires similar client and provider information, including service details and insurance coverage.
  • California Children's Services (CCS) Application: This form is used to apply for services under the CCS program. It gathers client information, including medical history and eligibility, much like the DHS 4516 form collects similar data for dental services.
  • Denti-Cal Claim Form: This form is submitted by dental providers to request payment for services rendered to Medi-Cal recipients. It shares the need for detailed client and service information, similar to what is required in the DHS 4516.
  • Prior Authorization Request Form: This document is used to obtain prior approval for specific medical services. It parallels the DHS 4516 in requiring detailed descriptions of the requested services and client information.
  • Health Insurance Portability and Accountability Act (HIPAA) Authorization Form: This form is used to authorize the release of medical information. While it focuses on privacy, it still requires client identification and service details, similar to the DHS 4516.
  • Patient Registration Form: This document collects basic information about a patient, including demographics and insurance details. It serves a similar purpose to the client information section of the DHS 4516.
  • Dental Treatment Plan: This form outlines the proposed dental treatments for a patient. It includes similar service descriptions and client information as found in the DHS 4516.
  • Authorization for Release of Information Form: This document allows healthcare providers to share patient information. It requires client identification and can be seen as similar to the DHS 4516 in its focus on client details.

Dos and Don'ts

When filling out the California DHS 4516 form, there are important dos and don'ts to keep in mind. Here’s a helpful list:

  • Do provide accurate and complete information for all required fields.
  • Do ensure that the client's residence address does not include a P.O. Box.
  • Do check the appropriate boxes for insurance enrollment to avoid delays.
  • Do sign the form before submission to validate the request.
  • Don't leave any mandatory fields blank; this can lead to rejection of the request.
  • Don't mix different types of procedure codes when filling out the service section.
  • Don't forget to include any necessary attachments or documentation.
  • Don't submit the form without verifying all information for accuracy.

Misconceptions

Understanding the California DHS 4516 form can be challenging due to several misconceptions. Here are eight common misunderstandings explained:

  • The form is only for orthodontic services. Many believe that the DHS 4516 form is exclusively for orthodontic requests. In reality, it is used for various dental services, including those for established CCS clients.
  • Only dentists can submit the form. While it is primarily used by dental providers, authorized representatives can also submit the form on behalf of clients. This allows for greater flexibility in the process.
  • The form is not necessary if a client has private insurance. Some think that having private insurance eliminates the need for this form. However, if the services are covered under CCS, the form may still be required to obtain authorization.
  • All information must be filled out completely. While it is important to provide as much information as possible, certain fields can be left blank if they are not applicable or if the information is unknown.
  • The form can be submitted without a signature. A common misconception is that the form can be submitted without a signature. In fact, it must be signed by the dental provider or an authorized designee to be considered valid.
  • Submission guarantees approval for services. Many assume that submitting the form guarantees approval. However, the authorization is subject to review and is not guaranteed simply by submission.
  • The form is only for children. While the California Children’s Services (CCS) program primarily serves children, the form can also be used for certain services for eligible adults under specific circumstances.
  • Once submitted, the request cannot be modified. Some people believe that after submission, the request is set in stone. In reality, modifications can be made if necessary, but it may require additional documentation or a new submission.

By clarifying these misconceptions, individuals can better navigate the process of using the California DHS 4516 form and ensure that they are properly submitting requests for dental services.

Key takeaways

Filling out the California DHS 4516 form can be a straightforward process if you keep a few key points in mind. This form is essential for requesting dental and orthodontic services for clients under the California Children’s Services (CCS) program. Here are some important takeaways to help you navigate the form effectively:

  • Accurate Information is Crucial: Ensure that all details, from the provider's name to the client's birth date, are entered accurately. Mistakes can lead to delays in service authorization.
  • Use the Correct Codes: When filling out the service request section, use the appropriate Denti-Cal codes for procedures. Mixing different types of codes can result in complications.
  • Contact Information Matters: Provide complete contact details for the provider and a designated contact person. This ensures that any questions or issues can be addressed promptly.
  • Understand Insurance Requirements: Be clear about the client's insurance status. If the client is enrolled in Medi-Cal, you must send the Treatment Authorization Request (TAR) directly to Denti-Cal, not CCS.
  • Sign and Date the Form: Remember that the form must be signed by the dental provider or an authorized designee. Failing to do so can invalidate the request.

By keeping these points in mind, you can help streamline the process and ensure that your requests are processed efficiently. Filling out forms accurately not only saves time but also supports better care for clients.