Form DHCS9086 "California Children's Services Maintenance and/or Transportation Authorization" - California

What Is Form DHCS9086?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2008;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS9086 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS9086 "California Children's Services Maintenance and/or Transportation Authorization" - California

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State of California Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Maintenance and/or Transportation Authorization
Issue Date:
To:
(Name and Address)
CCS Client Name:
CCS Number:
Date of Birth:
California Children’s Services has authorized the following transportation and/or maintenance
services for the above client and/or responsible adult caregiver:
ƒ Lodging ____ Night(s) at a maximum cost of $__________ per night, at __________________.
ƒ Meals
Actual costs up to $15/day/person for ___ person(s).
ƒ Transportation
ƒ Mileage Reimbursement up to maximum cost of $
______
.
ƒ Mode of Travel: _____________ up to maximum cost of $______/person for ___ person(s).
ƒ Associated Costs (e.g., parking, tolls) actual cost up to $___________.
Services Authorized for the Period of ______________ to ______________.
Comments:
Additional prior authorization is needed for all additional expense requests.
Directions:
ƒ Receipts are required for all claimed expense (except for gasoline which is reimbursed
based on miles of needed travel).
ƒ For reimbursement, submit receipts for all costs along with a copy of this authorization.
ƒ Submit claim and receipts within ____ days of completed travel to:
(Local CCS Program Name and Address)
If you have questions, please call CCS at (
)
Failure to comply with these requirements may result in the client/caregiver being excluded
from future use of the CCS maintenance and transportation benefit.
CCS Staff Signature
DHCS (02/08)
Page 1 of 1
State of California Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services Branch
California Children’s Services
Maintenance and/or Transportation Authorization
Issue Date:
To:
(Name and Address)
CCS Client Name:
CCS Number:
Date of Birth:
California Children’s Services has authorized the following transportation and/or maintenance
services for the above client and/or responsible adult caregiver:
ƒ Lodging ____ Night(s) at a maximum cost of $__________ per night, at __________________.
ƒ Meals
Actual costs up to $15/day/person for ___ person(s).
ƒ Transportation
ƒ Mileage Reimbursement up to maximum cost of $
______
.
ƒ Mode of Travel: _____________ up to maximum cost of $______/person for ___ person(s).
ƒ Associated Costs (e.g., parking, tolls) actual cost up to $___________.
Services Authorized for the Period of ______________ to ______________.
Comments:
Additional prior authorization is needed for all additional expense requests.
Directions:
ƒ Receipts are required for all claimed expense (except for gasoline which is reimbursed
based on miles of needed travel).
ƒ For reimbursement, submit receipts for all costs along with a copy of this authorization.
ƒ Submit claim and receipts within ____ days of completed travel to:
(Local CCS Program Name and Address)
If you have questions, please call CCS at (
)
Failure to comply with these requirements may result in the client/caregiver being excluded
from future use of the CCS maintenance and transportation benefit.
CCS Staff Signature
DHCS (02/08)
Page 1 of 1