Children's Special Health Services
If you would like to apply to Childrens Special Health Services (CSHS) for financial assistance, please read the following information and fill out the PDF form at the bottom of this page. If this form is not working for you and you wish to submit an e-mail message directly to the Webmaster you can use: firstname.lastname@example.org
You do not have to apply for financial assistance to attend a specialty clinic, you can obtain more information regarding clinic services at: available clinic services
To request financial assistance for medical care, please provide the following:
- Completed, signed and dated application.
- Two months current paycheck stubs of all persons living in the household for income verification. (exception - if an individual is under 23 years of age and attending school, CSHS does not count their earned income.)
- If self-employed attach a copy of the front page of your current year 1040 federal tax form. Also include a copy of your profit and loss such as schedule "C", "F" etc.
- Provide verification of child, disabled or elderly adult care while you and your spouse are working.
- Current physician notes regarding medical condition for which you are applying. Contact your physician's office to have the notes faxed to CSHS: contact CSHS
- When requesting coverage for medication, please provide CSHS with the name of your preferred pharmacy in the space provided on the application.
This information will be used to determine eligibility and allow release of information to appropriate caregivers. All information will be kept strictly confidential.
Once a decision is rendered the applicant will be notified by mail. Eligibility beings on the date CSHS receives the completed application including all documents requested in the office and goes through September 30th of the Federal Fiscal Year. In general financial eligibility will be determined within thirty(30) days after receipt of a completed application, including supporting documents.
A decision will not be rendered in any of the following circumstances:
- The application is voluntarily withdrawn
- The applicant cannot be located
- The application process is not completed
Make application to CSHS for financial assistance:
- Download the PDF form.
- Enter all information requested on the form.
- Upon completion, the form must be printed out in order to "save" what you have entered. If you close the PDF form and don't print out what you have entered, your information will be lost. The information entered into the PDF form cannot be saved.
- Fill in any additional information by hand, if necessary.
- Mail or Fax the completed form to CSHS at: contact CSHS
You can also obtain an application from CSHS for financial assistance by using the following:
- Download the PDF form, print it out, fill it in by hand, mail or Fax it to the CSHS at: contact CSHS
- Call CSHS at: contact CSHS
- Contact your Local Public Health Agency at: local public health
- Contact one of the Regional Clinic site at: clinic contacts
When filling out the form on your computer, you can use the following tools:
- Click on a field with your mouse to select the field. A cursor will appear and you can type in your information.
- The Tab key will move you forward from field to field. Shift + Tab key will move you backwords from field to field.
- Delete an entry by highlighting the information and pressing delete, backspace, or just type over the highlighted information.
- Check boxes can be checked by clicking on the box with your mouse or by selecting the box and pressing the Enter key or space bar. (Hitting the Enter key or space bar again will remove the checkmark.)
- Standard Windows-based commands will work in the PDF file. Control + C will copy, Control + V will paste and Control + X will cut.
The following tools only work when the cursor is not in a field:
- Arrow keys right and left move page to page through the document. Arrow keys up and down scroll thought the document.
- The Enter key will move you through the document a half-page at a time.