CCS Application and Service Agreement Forms

Provider Type

  • Physicians
  • Participating Physician Groups (PPG)
  • Hospitals
  • Ancillary

A signed Application to Determine CCS Program Eligibility (PDF) on file with the California Children's Services (CCS) program provides a legal right to appeal if services are denied by the CCS program.

CCS and Health Net strongly recommend that the CCS application and service agreement be completed to ensure that the member receives CCS program benefits. If the application is on file with CCS, the member may continue to receive services through CCS even if the member loses plan eligibility.