Form Mc 5121ad - County/direct Provider Approver Certification
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1State of California - Health and Human Services Agency
Department of Health Care Services
County/Direct Provider Approver Certification
DHCS Approved
(DHCS use only)
Date
Approver
For Access to Confidential DHCS Drug Medi-Cal Information Data
County:
(County Name and Code)
Direct Provider:
(Direct Provider Name and Four Digit DMC Number(s)
To ensure the confidentiality of county/direct provider Drug Medi-Cal (DMC) data, the Department of Health Care Services
(DHCS) requests the County AOD Administrator or Direct Provider Executive Officer designate a primary and a secondary contact to
be responsible for approving county/direct provider staff requests for access to confidential patient data in the Short-Doyle/Medi-
Cal Claims system. 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.
Primary Approver:
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: : (
)
Email Address:
Primary Approver’s Signature:
(Signer acknowledges having read the attached Confidentiality Statement for all DHCS AOD users of the ITWS)
Secondary Approver:
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: : (
)
Email Address:
Secondary Approver’s Signature: ______________________________
____________________
(Signer acknowledges having read the attached Confidentiality Statement for all DHCS AOD users of the ITWS)
Appointed Vendor(s):
(If applicable)
The vendor listed below has the authority to receive, send and process the above named county/direct provider’s confidential
DHCS Drug Medi-Cal information in the Short-Doyle / Medi-Cal Claims system. The vendor will establish its own
primary and secondary approving contacts.
Vendor Name:
Vendor Contact Name:
Phone Number: (
)
DHCS AOD Administrator/Executive Officer Certification:
As the AOD Administrator or Executive Officer for
(
, I designate the above
County/Direct Provider)
individuals and vendor, if applicable, to have independent authority to approve access requests to specific confidential Drug Medi-
Cal patient data. DHCS may rely on approvals, denials, and changes made by the above individuals/vendor in its processing of access
requests to this county/direct provider’s data in the systems listed above. As changes occur to the above approving contacts or
vendor information (name, phone, e-mail, or fax), I will sign an updated certification and forward it to DHCS. Also, I acknowledge
reading the Confidentiality Statement for all DHCS AOD users of the ITWS.
DHCS AOD Administrator/Executive Officer
(signed and printed)
Date
MC 5121AD (6/12)
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