Form Dhcs 4015 U - Patient History Transaction - State Of California Health And Human Services Agency

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State of California—Health and Human Services Agency

Department of Health Care Services

California Children’s Services

PATIENT HISTORY TRANSACTION

Trans. code

State file number

Patient name

Last

First

M.I.

Birth date (month/day/year)

Sex

Race

1—Male

1—White

3—Spanish surname

5—American Indian

7—Other Nonwhite

2—Female

2—Black

4—Asian

6—Filipino

8—No response

3—Unknown

9—Unknown

Reporting county

Residence county (if different than reporting county)

Birth place—county or state or other country

Mother’s maiden name

Presumptive CCS

Eligible Dx

Referral source

Referral date (month/day/year)

1—Parent

4—Other provider

7—School

2—Hospital

5—CHDP/EPSDT

8—DD regional center

3—Physician

6—CCS case finding

9—Other

Disposition of case

Completed by / date

1—Diagnosis only

3—Diagnosis and waiting list

2—Diagnosis and treatment

4—Therapy only

Changes or closures are to be made on a photocopy of this transaction!

DO NOT enter changes or closures on the original copy of this transaction!

Notice of Change of Information

Report of Case Closure

(Enter only information to be changed.)

(enter code here)

Reopen case

Patient name

(last)

Reasons for case closure (use one only)

(first)

01—Treatment completed

02—Eligible condition cured

(m.i.)

03—No treatment indicated at this time

Birth date

(month/day/year)

04—Patient reached 21 years of age

05—Residence established in another county

Sex

1—Male

2—Female

3—Unknown

06—Residence established in another state

Race

1—White

4—Asian

7—Other Nonwhite

07—No response at last known address

2—Black

5—American Indian

8—No response

3—Hispanic

6—Filipino

9—Unknown

08—Medically ineligible

09—Financially ineligible

Reporting county

10—Parents will handle privately

Residence county

11—Referred to another treatment source

12—Death of patient

Birth place

(county, state, or other country)

13—Family covered by prepaid health plan

14—Unable to keep appointments

Mother’s

maiden name

10.

19—Other (specify)

(last name only)

Effective date of closure

Presumptive Dx

11.

month

day

year

County

Source of information

Referral source

12.

1—Parent

4—Other provider

7—School

2—Hospital

5—CHDP/EPSDT

8—Regional center

3—Physician

6—CCS case finding 9—Other

Completed by

Referral date

13.

Date

Month

Day

Year

PRIVACY NOTIFICATION

This information is requested by the California Children’s Services Program of the State Department of Health Care Services, under Section 123800 et seq. of the California

Health and Safety Code, in order to provide medical treatment services. Completion of the form is required and services may be denied when not providing the information.

Information will be provided to the State Department of Health Services and the county in which you reside. For more information or access to your records, contact Children’s

Medical Services, Program Support Section, P.O. Box 997413, MS 8100, Sacramento, CA 95899-7413; telephone (916) 327-1400.

DHCS 4015 U (01/08)