Form Mc 5123ad - Dhcs Employee Approver Certification
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1State of California - Health and Human Services
Department of Health Care Services
DHCS Employee Approver Certification
DHCS Approved
(DHCS use only)
Date
Approver
For Access to Confidential DHCS Drug Medi-Cal
DHCS Branch :
To ensure the confidentiality of Drug Medi-Cal (DMC) data, the Department of Health Care Services (DHCS) requests
the appropriate DHCS Manager designate a primary and a secondary contact to be responsible for approving
employee requests for access to confidential patient data in the Short-Doyle/Medi-Cal claims system. Please provide this
information in the spaces below and fax this form to (916) 323-0653. If you have any questions about this form,
please call (916) 323-2043.
Primary Approver:
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: : (
)
Email Address:
Primary Approver’s Signature: __________________________________________________
(Signer acknowledges having read the Confidentiality Statement for all DHCS AOD/ITWS users)
Secondary Approver:
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: : (
)
Email Address:
Secondary Approver’s Signature:
(Signer acknowledges having read the Confidentiality Statement for all DHCS AOD/ITWS users)
DHCS Certification:
As Manager of
, I designate the above individuals to have
(unit name)
independent authority to approve access requests to specific confidential Drug Medi-Cal data. The DHCS may rely on
approvals, denials, and changes made by these individuals in its processing of access requests to the Short-Doyle/Medi-Cal
claims system. As changes occur to the above approving contact’s information (name, phone, e-mail or system), I will sign
an updated certification and forward it to DHCS ITWS. Also, I acknowledge reading the Confidentiality Statement for all
DHCS AOD users of the ITWS.
_________________________________________________________________
_________________
Manager
(signed and printed)
Date
MC 5123AD (6/12)
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