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Exhibit E

HEALTHY FAMILIES PROGRAM RECORD FORMS FOR REFERRALS TO CALIFORNIA CHILDREN SERVICES

The Exhibit contains examples of various forms and reference materials, which Healthy Families Program Providers and Health Plans will need to use when making referrals to California Children Services (CCS) for the eligible conditions.

E-1

CCS Program Referral Form and Referral Definitions

E-2

CCS Informational Flyer

E-3

CCS Program Application for Services

E-4

CCS Medical Eligibility Regulations

E-5

CCS Provider Flow Chart, CCS Communication Flow Chart

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