Form Dhcs4507 - California Special Care Center Directory Update Fax Cover Sheet - Health And Human Services Agency

Download a blank fillable Form Dhcs4507 - California Special Care Center Directory Update Fax Cover Sheet - 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 Dhcs4507 - California Special Care Center Directory Update Fax Cover Sheet - 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.

ADVERTISEMENT

State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services Branch
SPECIAL CARE CENTER DIRECTORY UPDATE
FAX COVER SHEET
To:
Provider Services Unit
From:
Children’s Medical Services Branch
Fax:
916-322-8798
Phone:
Date:
Total pages:
Printed name of Medical Director
Signature of Medical Director
DIRECTIONS FOR UPDATING SPECIAL CARE CENTER DIRECTORY LISTING
1. Find and print your SCC directory listing in the Special Care Center section of the CCS website
( ).
2. Write the changes (including additions or removals of staff) directly on your SCC directory listing.
Print clearly with dark ink. Use an additional sheet of paper if necessary.
3. If staff have been added to or removed from your SCC directory listing, supply their active Provider
Number, discipline, and effective date(s) using the table below:
Effective Date
Name
Discipline
Provider Number
Action
(mm/dd/yy)
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
CMS USE ONLY
4. Complete the top portion of this cover sheet. The Medical
Received:
_____________
Director must sign this cover sheet.
Entered in database:
_____________
Regional Office approval: _____________
5. Fax the completed cover sheet and your edited SCC
Sent to pending:
_____________
directory listing to 916-322-8798.
Notes: ____________________________
__________________________________
__________________________________
6. Updates are made routinely. Changes are posted on the
__________________________________
CCS website at the end of each workweek.
DHCS4507 (01/08)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Dhcs 7037 - California Pickle Resource Work Sheet - Health And Human Services Agency Form Dhcs 7037 - California Pickle Resource Work Sheet - Health And Human Services Agency Legal
Form Dhcs 7020 - California Screening Work Sheet - Health And Human Services Agency Form Dhcs 7020 - California Screening Work Sheet - Health And Human Services Agency Legal
Form Dhcs 7021 - California Financial Eligibility Work Sheet - Health And Human Services Agency Form Dhcs 7021 - California Financial Eligibility Work Sheet - Health And Human Services Agency Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (spanish) - Health And Human Services Agency Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (spanish) - Health And Human Services Agency Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (hmong) - Health And Human Services Agency Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (hmong) - Health And Human Services Agency Legal
Form Dhcs 5102 - California Caloms Itws County/direct Provider/vendor User Cancellation - Health And Human Services Agency Form Dhcs 5102 - California Caloms Itws County/direct Provider/vendor User Cancellation - Health And Human Services Agency Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (arabic) - Health And Human Services Agency Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (arabic) - Health And Human Services Agency Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (armenian) - Health And Human Services Agency Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (armenian) - Health And Human Services Agency Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (chinese) - Health And Human Services Agency Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (chinese) - Health And Human Services Agency Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (korean) - Health And Human Services Agency Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (korean) - Health And Human Services Agency Legal

Related Categories

Parent category: Legal
Download
Go