Forms and additional information

Medical Information Release- This form must be filled out and given to any specialist you wish to submit medical reports to CSHCS to determine eligibility. It also used if you or your child are due for a medical review. 

CSHCS Application-The CSHCS application form will be sent if you or your child has been deemed medically eligible for the program. Medical eligibility must be determined before submitting an application.

Income Review Payment Agreement (IRPA)-This form must be filled out in conjunction with the application when enrolling in CSHCS. It is also filled out yearly for you or your child’s financial review in order to continue enrollment in CSHCS (only for families without Medicaid).

Payment Agreement guide-Use this form to assist you in filling out the Income Review Payment Agreement (IRPA).

Macomb County Privacy Practices-After enrolled, please review this form (privacy practices) then sign and return this signature form only. This form only needs to be completed once.

Under 18 Release of Information- Complete this form if you would like to authorize someone other than yourself to speak with CSHCS staff regarding your child’s health and insurance information.

Over 18 Release of Information- Complete this form if you would like to authorize someone other than yourself to speak with CSHCS staff regarding your child’s health and insurance information.