Form Mc 5120ad - Vendor Approver Certification
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1State of California - Health and Human Services Agency
Department of Health Care Services
Vendor Approver Certification
DHCS Approved
(DHCS use only)
Date
Approver
For Access to Confidential DHCS Drug Medi-Cal Information
Vendor:
To ensure the confidentiality of county/direct provider Drug Medi-Cal data, the Department of Health Care Services (DHCS)
requests the designated vendor identify a primary and a secondary contact to be responsible for approving requests for access t o
confidential county/direct provider Drug Medi-Cal patient data. Please provide this information in the spaces below and fax this
form to (916) 323-0653. If you have questions about this form, please call (916) 323-2043.
Primary Vendor 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 users of the ITWS)
Secondary Vendor 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 users of the ITWS)
Vendor for the Following Counties/Direct Providers:
(Please indicate two digit County number, four digit DMC Direct Provider number)
Vendor Certification:
As
for
, I certify this organization is a v endor for
(title)
(vendor)
the above counties/direct providers and designate the individuals identified above to have independent authority to approve access
requests to specific confidential county/direct provider Drug Medi-Cal patient data. DHCS may rely on approvals, denials, and
changes made by these individuals in its processing of access requests for the above listed counties’/direct providers’ data. As
changes occur to the above approving contacts (name, phone, e-mail or county/direct provider), I will complete a new certification
and forward it to DHCS. Also, I acknowledge reading the Confidentiality Statement for all DHCS AOD users of the ITWS.
Date:
Name/Signature: _________________________________________________ (printed/signed)
Title: _________________________________________________
MC 5120AD (6/12)
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