CCS Family Application

Application for Services:

This application is to be completed by the parent, legal guardian or applicant, if the applicant is 18 years or older. "Applicant" means the child for whom the services are being requested. PLEASE READ ALL THE INFORMATION ON THIS APPLICATION.

California Department of Health Services Application to Determine CCS Program Eligibility (DHS4480)

CCS Family Application- English   -  la Aplicación de CCS en Español

You may download and complete these forms on your computer. You may return them to CCS by FAX (805 681-4763) OR by mail:

CCS
345 Camino Del Remedio
Santa Barbara, CA 93110

Call CCS to verify the receipt of these forms.