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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