Get ready to apply
California Department of Health Care Services
California Children's Services
What you get
Help coordinating diagnosis, treatment, medical case management, and specialty services. Ask whether requests are open.
- Who starts it
- You
- How it’s sent
- By post
- Your time
- An hour or so
- Last checked
- Aug 27, 2026
Before you start, check you fit
- Your child is 20 or under.
- Ask when you should expect a decision after submitting your application.
- Expected out-of-pocket medical expenses above 20% of family AGI may satisfy the financial rule.
-
What their form asksA preview, so you can gather things first. Fill it in on their site.
Open the application PDF ↗ Checked Aug 27, 2026Send it by post to the address on the form.
What the form asks for
DHCS 4480 application questions1. Name of ApplicantName on birth certificate (if different); any other name2. Date of birth (month, day, year)3. Place of birth — County, State, Country if outside U.S4. Applicant’s residence address (do not use a P.O. Box)5. Sex6a. What is the applicant’s gender6b. What sex was listed on the applicant’s original birth certificate6c. Does the applicant think of them self as7. Race / Ethnicity8. Social Security Number (optional)9. What is the applicant’s suspected eligible CCS condition or disability10. Primary Care Physician11. Physician’s phone number12. Name of parent or legal guardian13. Mother’s first name and maiden name14. Residence address (do not use a P.O. Box)15. Mailing address (if different from 14)16. Home phone number17. Cell phone number18. Work phone number19. What language do you speak at home20. Email address21. Number of persons in family unit22. Other Parent Last and First Name and address (if not living with applicant)23. Does the applicant have Medi-Cal24. If yes, what is the applicant’s Medi-Cal number25. Is there a share of cost26. If yes, what is the amount you pay per month27a. Does the applicant have other health insurance27b. If yes, what is the name of the insurance plan or company27c. Policy or Plan Number28. Type of insurance plan or company29. Does the applicant have dental insurance30. Does the applicant have vision insuranceSignature of person completing the applicationHave ready
- Completed DHCS 4480 application with initials, signature, and date.
After you send
Contact the county CCS office for help completing the form or to confirm receipt. If you have not heard back in two weeks, write and ask whether it arrived.