Form Dhcs 4518 - California Provider Electronic Data Interchange (Pedi) Domain Update - Health And Human Services Agency

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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:
PROVIDER ELECTRONIC DATA INTERCHANGE
Scan and email:
cmshelp@dhcs.ca.gov
(PEDI) DOMAIN UPDATE
Contact the CMS Net Help Desk
Questions?
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This form is used to add/delete National Provider Identifiers (NPI) or Special Care Centers (SCC) to a PEDI domain.
Adding NPIs/SCCs to your domain allows users in your domain access to authorizations, denials, referrals, letters,
reports, and client information for that NPI/SCC. Please type or print legibly. If more than 25 NPIs/SCCs are to be
added to this domain, please use an Excel worksheet or alternative electronic format. This form is not applicable to
Healthy Families or Medi-Cal Managed Care Health Plans.
Provider Facility Name:
Select One
NPI/SCC Name
NPI/SCC Number
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Phone:
Liaison’s Name (Print):
Date:
Liaison’s Name (Signature):
Note: In accordance with item #5, Provider Responsibilities in the PEDI Application, you shall maintain written permission from
the providers within your domain to access their individual authorizations.
DHCS 4518 (05/13)
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