Attention! Nationwide recall of certain apple sauce pouches due to possible contamination with lead. Learn more.

Effective July 15th, Health Services for Children with Special Needs (HSCSN) will implement Optum Financial/Optum Pay as the check payment vendor for provider electronic funds transfer (EFT). The details to the provider letter can be found in this document.

Health Services for Children with Special Needs, Inc. (HSCSN)

Enrollee Forms

Transportation

HSCSN Family Therapy Travel Fact Sheet [PDF - 370 KB]
Unaccompanied Enrollee Consent Form - English [PDF - 956 KB]
Unaccompanied Enrollee Consent Form - Spanish [PDF - 1.12 MB]

Pharmacy Benefits

Formulary Prior Authorization and Exception Form [PDF - 455 KB]
CVS Mail Order Fax Form [PDF - 650 KB]

Out-of-Pocket Reimbursement of Medical Costs

Reimbursement Request Form - English [PDF - 2 MB]
Reimbursement Request Form - Spanish [PDF - 2 MB]

HSCSN Benefits

Benefits Covered [XLS - 36 KB]

Behavioral Health

AprilMay Referral Form [PDF - 712 KB]

Referrals

Out of Network Services Referral Form [PDF - 184 KB]

Rehabilitative Services

Rehabilitative Services Request Form [PDF - 170 KB]