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CSHCS and MSA Forms

Children's Special Health Care Services
Guidance Manual for Local Health Departments
Appendix D

The forms listed below that have "SAMPLE" written on them are for Local Health Department use only. Those that can be printed are in "Word". Forms are revised on an ongoing basis. Please pay close attention to the revision date in the lower left corner of the form to be sure you are using the most current version.


Form Number

Name & Description

DCH-0078 Request to Add, Terminate or Change Other Insurance
DCH-0092 Request for Administrative Hearing and Instructions
DCH-0093 Request for Withdrawal of Appeal
DCH-0367 Hearing Summary
DCH-0892 Request for a Department Review
DCH-0923 Department Review Summary
DCH-1183 Authorization to Disclose Protected Health Information
DCH-1239/1273 Children with Special Needs Fund Application, Guidelines & Financial Assessment
DCH-1242 Documentation Supplemental Attachment to CPBC FSR (Fin-134)
DCH-1354-A Third Party Liability Health Casualty Insurance Information


Request to Participate in Policy Proposal Review

MSA-0300 Beneficiary Complaint (Medicaid Beneficiary)
MSA-0636 Client Transportation Authorization and Invoice (CSHCS)
MSA-0650 Referral and Authorization for CSHCS Diagnostic Evaluation
MSA-0709 Non-Emergent Medical Transportation and Verification
MSA-0725 Application for Payment of Health Insurance Premiums (CSHCS)
MSA-0730-B Notice of Action form Local Health Department (NOA)
MSA-0732 Prior Authorization for Private Duty Nursing (PDN)
MSA-0737 Children's Special Health Care Services (CSHCS) Application
MSA-0738 Income Review /Payment Agreement
MSA-0738-B Payment Agreement Guide for CSHCS
MSA-0741 CSHCS Beneficiary Service Needs Summary Record
MSA-0742 Financial Worksheet
MSA-0743 CSHCS Beneficiary Service Needs Questionnaire
MSA-0838 Release to Obtain Medical Information
MSA-0927 Income Review /Payment Agreement Amendment
MSA-0947 Reimbursement for Clinic Participation (CSHCS)
MSA-4114 Medical Eligibility Form (MERF)
MSA-6544-B Practitioner Special Services Prior-Approval - Request/Authorization