Form Dhcs 4510 - California Medical Therapy Program Mtp Therapist Table - 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
MEDICAL THERAPY PROGRAM (MTP) THERAPIST
Submit Form:
Scan and email:
cmshelp@dhcs.ca.gov
TABLE
Contact the CMS Net Help Desk
Questions?
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This request is for adding, modifying, and deleting therapists on the Medical Therapy Unit (MTU) treatment staff
table only. Please type or print legibly and allow one week for processing new requests.
County:
Select One
Position
Name (Last, First)
MTU Action
MTU Name
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Add
OT
Add to
Modify
PT
Inactive from
Delete
Aide/Asst. for PT
Aide/Asst. for OT
Phone:
Requestor’s Name (Print):
Requestor’s Title:
Date:
DHCS 4510 (Rev 05/13)

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