Form Dhcs 4513 - California Cms Net Account Request - Department Of Health Care Services Children'S Medical Services (Cms) Branch

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State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services (CMS) Branch
Fax: (916) 440-5346 or
Submit Form:
CMS NET ACCOUNT REQUEST
Scan and email:
cmshelp@dhcs.ca.gov
Contact the CMS Net Help Desk
Questions?
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This form is to request CMS Net system access activation, modification or deletion for State, county and
local program staff supported by the CMS Branch. When the “Add” option is selected the user will be
assigned a new User ID and temporary password. The form is also to be used to request modification or
deactivation of a user ID. Please type or print legibly. All fields marked with an asterisk (*) are required.
County*:
Select
Security Level
Phone*
One*
(default access leave blank)
Name (Last, First)* and Email*
Credentials
(999)999-9999 Alternate County
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Add
County System Admin
Modify
Co System Admin-Plus
Delete
MTP Add/Modify/Review
SAR EPSDT
SAR Override
Phone*:
Representative’s Name (Print)*:
Date*:
Representative’s Name (Signature)*:
DHCS 4513 (Rev 05/13)

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