Form Mc 5131ad - County/direct Provider User Cancellation

Download a blank fillable Form Mc 5131ad - County/direct Provider User Cancellation in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Mc 5131ad - County/direct Provider User Cancellation with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

State of California - Health and Human Services Agency
Department of Health Care Services
For Canceling User Access to Confidential DHCS Drug Medi-Cal
County/Direct Provider/Vendor:
To ensure the confidentiality of county/direct provider Drug Medi-Cal (DMC) data, the Department of Health Care Services
(DHCS) requests the County DHCS AOD Administrator, Direct Provider Executive Officer or Vendor Executive Officer to
notify DHCS when previously approved users should no longer be allowed access to confidential patient data in the system listed
below. Please complete the information below and fax this form to (916) 323-0653. If you have questions about this form,
please call (916) 323-2043.
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
DHCS AOD Administrator/Executive Officer Certification:
As AOD Administrator/Executive Officer for
(County/Direct Provider/Vendor),
I designate the above individual(s) no longer has/have access requests to specific confidential Drug Medi-Cal patient data.
DHCS AOD Administrator/Executive Officer
(signed and printed)
Date
MC 5131AD (6/12)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go