Form Dhcs 4087 - California Master Index Rejection Notice - Health And Human Services Agency

Download a blank fillable Form Dhcs 4087 - California Master Index Rejection Notice - Health And Human Services Agency in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dhcs 4087 - California Master Index Rejection Notice - Health And Human Services Agency with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Department of Health Care Services

State of California—Health and Human Services Agency

California Children’s Services (CCS)

MASTER INDEX REJECTION NOTICE

Program Support Section

P.O. Box 997413

(Coding hints: No Decimals—No Spaces)

Sacramento, CA 95899-7413

(916) 327-1400

Please submit the needed information requested below to CCS Headquarters. Thank you.

1. More specific code

10. Correct form

❒

2. Code for each diagnosis

11. Correct state file number

❒

3. Five digit ICD-9 Code

12. Complete information

❒

4. Underlying and/or primary diagnosis code

13. “Notice of Change of Information,” DHS 4015

❒

5. Medically eligible diagnosis code

14. Copy of original “Report of Case Opened” (if original does not contain

❒

information currently required, also submit current “Report of Case Opened.”

❒

Use old state file number.)

6. Code to reason for V code

❒

7. Correct/full name

15. “Report of Case Closure,” DHS 4015

❒

8. Correct birth date

16. Other

❒

9. New state file number (The attached number has been assigned to another patient.)

❒

Initiated by:

_____________________________________________________

________________

CCS Headquarters Master Index Unit

Date

DHCS 4087 (06/07)