Form MC2142 "California Children's Services Face Sheet" - California

What Is Form MC2142?

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 September 1, 2007;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MC2142 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 MC2142 "California Children's Services Face Sheet" - California

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Department of Health Care Services
State of California—Health and Human Services Agency
Children’s Medical Services Branch
CALIFORNIA CHILDREN’S SERVICES FACE SHEET
County of residence
Birthplace
Medi-Cal number
Effective date
California Children’s Services number
(county, other state, or country)
(attach copy of card if available)
Legal name
Nickname
Social Security number
Birth date (month, day, year)
Sex
(last, first, middle)
Male
Female
Unknown
Address
City
ZIP code
Telephone
Cross street or landmark
(number, street)
(
)
Mother
Maiden name
Social Security number
Birth date
(month, day, year)
Address
City
ZIP code
Telephone
(number, street)
(
)
Employer
Address
City
ZIP code
Telephone
(number, street)
(
)
Health insurance company
Address
City
ZIP code
Policy/group number
(number, street)
Father
Social Security number
Birth date
(month, day, year)
Address
City
ZIP code
Telephone
(number, street)
(
)
Employer
Address
City
ZIP code
Telephone
(number, street)
(
)
Health insurance company
Address
City
ZIP code
Policy/group number
(number, street)
Legal guardian
Address
City
ZIP code
Telephone
(number, street)
(
)
Foster parent/relationship
Address
City
ZIP code
Telephone
(number, street)
(
)
School
Grade
Telephone
Nurse
(
)
Address
City
ZIP code
(number, street)
Physician
Telephone
Send reports
(
)
Yes
No
Address
City
ZIP code
(number, street)
Specialist requested
Specialty
City
Telephone
(
)
Specialist requested
Specialty
City
Telephone
(
)
Reason for referral: Describe nature of physical handicap, significant associated conditions, dates of onset, date/types of treatment, and where care was received.
Factors that will assist CCS in planning care, e.g., transportation, language, social, housing,
Others in home (check CCS patients)
other agencies involved, previous CCS coverage
CCS?
Name
Birth Year Relationship to Patient
Presumptive CCS eligible diagnosis (CCS Use Only)
Race:
Referral source:
White
Hispanic/Latino
Filipino
Asian
American-Indian
Parent
Physician
CCS case finding
Other provider
CHDP—EPSDT
Black
Other nonwhite
No response
Unknown
School
Hospital
DD regional center
Other _______________________
Referred by:
Name
Title
Agency
Telephone
Date
(
)
Face sheet completed by:
Name
Title
Agency
Telephone
Date
(
)
MC 2142 (09/07)
Department of Health Care Services
State of California—Health and Human Services Agency
Children’s Medical Services Branch
CALIFORNIA CHILDREN’S SERVICES FACE SHEET
County of residence
Birthplace
Medi-Cal number
Effective date
California Children’s Services number
(county, other state, or country)
(attach copy of card if available)
Legal name
Nickname
Social Security number
Birth date (month, day, year)
Sex
(last, first, middle)
Male
Female
Unknown
Address
City
ZIP code
Telephone
Cross street or landmark
(number, street)
(
)
Mother
Maiden name
Social Security number
Birth date
(month, day, year)
Address
City
ZIP code
Telephone
(number, street)
(
)
Employer
Address
City
ZIP code
Telephone
(number, street)
(
)
Health insurance company
Address
City
ZIP code
Policy/group number
(number, street)
Father
Social Security number
Birth date
(month, day, year)
Address
City
ZIP code
Telephone
(number, street)
(
)
Employer
Address
City
ZIP code
Telephone
(number, street)
(
)
Health insurance company
Address
City
ZIP code
Policy/group number
(number, street)
Legal guardian
Address
City
ZIP code
Telephone
(number, street)
(
)
Foster parent/relationship
Address
City
ZIP code
Telephone
(number, street)
(
)
School
Grade
Telephone
Nurse
(
)
Address
City
ZIP code
(number, street)
Physician
Telephone
Send reports
(
)
Yes
No
Address
City
ZIP code
(number, street)
Specialist requested
Specialty
City
Telephone
(
)
Specialist requested
Specialty
City
Telephone
(
)
Reason for referral: Describe nature of physical handicap, significant associated conditions, dates of onset, date/types of treatment, and where care was received.
Factors that will assist CCS in planning care, e.g., transportation, language, social, housing,
Others in home (check CCS patients)
other agencies involved, previous CCS coverage
CCS?
Name
Birth Year Relationship to Patient
Presumptive CCS eligible diagnosis (CCS Use Only)
Race:
Referral source:
White
Hispanic/Latino
Filipino
Asian
American-Indian
Parent
Physician
CCS case finding
Other provider
CHDP—EPSDT
Black
Other nonwhite
No response
Unknown
School
Hospital
DD regional center
Other _______________________
Referred by:
Name
Title
Agency
Telephone
Date
(
)
Face sheet completed by:
Name
Title
Agency
Telephone
Date
(
)
MC 2142 (09/07)