Forms

California Children's Services (CCS)

• Established CCS Client Service Authorization Request (DHS 4509)
• Neurologic Findings Note
• Patient Information Brochure:  English  |  Spanish
• Patient CCS Information / Application Packet:  English  |  Spanish
• Riverside County:  Parent Application  |  Referral  |  Packet
• San Bernardino County:  Parent Application  |  Referral  |  Packet

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Certificate of Medical Necessity / Medical Justification

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Child Protective Services (CPS)

• Reporting Form
• CPS - Riverside: (800) 442-4918
• CPS - San Bernardino reporting phone is now: (909) 384-9233  |   FAX: (909) 388-6718

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Confidential Morbidity Report Form

San Bernardino County:

• Confidential Morbidity Report Form for non- Tuberculosis and non-DMV reporting 
• Confidential Morbidity Report Form for Tuberculosis
• Confidential Morbidity Report Form for DMV

Riverside County:

• Confidential Morbidity Report Form for non- Tuberculosis and non-DMV reporting 
• Confidential Morbidity Report Form for Tuberculosis 
• Confidential Morbidity Report Form for DMV 
• Confidential Morbidity Report Reporting Requirements

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Department of Motor Vehicles (DMV)

Website:

• Forms
• Disabled Placard Application (Reg 195)
• Driver Medical Evaluation (DS 326)
• Medical Examination Report (DL 51)

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Durable Medical Equipment / PT / Home Services

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HIV - AIDS

HIV - AIDS Case Report Form:  Adults  |  Children

HIV - AIDS Patient Log:  Excel Spreadsheet  |  PDF file

Informed Consent for Test

Soundex Numbers:

• Excel Spreadsheet Macro Soundex Generator
• Instructions to Generate Soundex Numbers
• Instructions for Excel Spreadsheet, Java, and Windows Application
• Windows Application (.zip file)

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Inland Regional Center

Early Start Program:  Brochure  |  Prevention Resource & Referral Services  |   Application

General Information:  English  |  Spanish

Old Brochure:  English  |  Spanish

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LifeWatch

LifeWatch Event Monitor - Physician Notification Criteria

LifeWatch 30-day Event Monitor Form  |  Old Form #2  |  Old Form #1

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Prior Authorizations / Pharmacy Exception Requests

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School Forms

• Authorization for Medication Administration:
  • Moreno Valley USD:  School Med Form  |  Self-Administration Medication Form  |  Authorization for Specialized Health Care
  • Riverside County #1:  MVMP  |  MV Pediatrics
  • Riverside County #2
  • Riverside County #3
  • San Bernardino City USD Form:  #1  |  #2
• California School Immunization Record
• Child Care Centers - Physician's Report
• Headstart / Preschool Physical Examination:  Blank  |  MVMP  | Mo Valley USD
• Home and Hospital Instructions - Moreno Valley USD:  #1  |  #2
• Loma Linda Academy - Student Physical Exam Form
• Report of Health Examiner:  English  |  Spanish
• San Bernardino City USD Entrance Exam

SAMPLE LETTER for parents to send to schools for Institutional Support Team

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WIC Forms

Alternate Formula Medical Justification:

• Riverside County (pg. 1) - Form
• Riverside County (pg. 2) - Policy Reference
• San Bernardino County

WIC Referral (half-sheets) - Blank

WIC Referral (half-sheets) - Riverside County

WIC Referral (full-sheets)

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West Nile Virus Forms

Information for Clinicians - San Bernardino County

Laboratory Slip and Case History:  Riverside County  |  San Bernardino County

Physician Alert - San Bernardino County

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