Form Pm 177 - 2012 - Chdp Provider Data Sheet For Local Chdp Program Use Only

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State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services
CHDP PROVIDER DATA SHEET
For Local CHDP Program Use Only
Local CHDP Program:
Date:
County/city program code
(
)
Prepared by:
Phone:
1. Transaction Code
2. Primary/Lab
3. Category
4. A. Status Code and Date Effective
1-Primary
1-Health assessment only
1 -
Active
A - New Provider Number/ NPI
B - Change of Information
3-Laboratory
3-Laboratory services only
2 - Inactive
C - Inactivate Provider Number
4-CCC with referrals
Month
Day
Year
D - Reactivate Provider Number
B.
5-CCC without referrals
E - Add Additional Location
Reason for Inactivation
F - Add New Owner
(See page 2 for codes)
5. Provider ID Number
6. Type
7. Tax ID Number or SSN
8. Phone Number
-
9. Legal Name/ Owner
10. Email Address
11. Name and Current Service Location (There is a limited number of characters per line, including spaces)
A. Last, First, Title
Name
B.
Use line B ONLY to extend name
C. Street
Service Location
(Include suite/room number or letter)
D. City
State
12. Name and New Service Location (There is a limited number of characters per line, including spaces)
A. Last, First, Title
13.
Name
B.
L.A.
Use line B ONLY to extend name
County Area Code
C. Street
Service Location
(Include suite/room number or letter)
D. City
State
14. Pay-to Name and Address
(There is a limited number of characters per line, including spaces)
A. Last, First, Title
Pay-to Name
B.
Use line B ONLY to extend name
C. Street
P.O. Box or “Pay-to” Address
D. City
State
ZIP Code
15. All other Provider ID numbers active in Medi-Cal or CHDP
16. CLIA number
Type:
Waiver
PPM
Certificate
Accreditation
17. Signature of CHDP Program Director or Deputy Director
DO NOT WRITE BELOW DOUBLE LINE— FOR STATE USE ONLY
Comments:
Date received:
Date processed:
Letter bypass
CHDP Flag on Medi-Cal
SEE SECOND PAGE FOR INSTRUCTIONS.
Page 1 of 2
PM 177 rev. (01-12)

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