Fillable Form Fc 5-Clist - Client List printable pdf download

Form Fc 5-Clist - Client List

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

CLIENT LIST

PROVIDER:

AUDIT PERIOD:

DATE

CLIENT NAME

FUNDING SOURCE

CLIENT SSN *

NOTE

PLACED

EXIT

* PERSONAL INFORMATION NOTICE

Pursuant to the Federal Privacy Act (P.L. 93-679) and the information Practices Act of 1977 (Civil Code Sections 1798, et. seq.), notice is hereby given for the request of personal information by this form. The requested personal

information is voluntary. The principal purpose of the voluntary information is to facilitate the processing of this form. The failure to provide all or any part of the requested information may delay processing of this form. No

disclosure of personal information will be made unless permissible under Article 6, Section 1798.17 of the IPA of 1977. Each individual has the right upon request and proper identification, to inspect all personal information in any

record maintained on the individual by an identifying particular. Direct any inquiries on information maintenance to your IPA Forms Officer.

FC 5 - CLIST (11/02)