Form Dhcs 4515 - California Children'S Services Program Individual Provider Paneling Application For Allied Health Care Professionals - Health And Human Services Agency

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Department of Health Care Services
State of California—Health and Human Services Agency
California Children’s Services (CCS) Program
INDIVIDUAL PROVIDER PANELING APPLICATION FOR
ALLIED HEALTH CARE PROFESSIONALS
Return completed form to:
California Department of Health Care Services
Children’s Medical Services Branch
IMPORTANT:
Provider Services Unit
Fields 1–11 are mandatory and must be completed; enter N/A if not applicable.
MS 8100
See attached instructions to complete this form.
P.O. Box 997413
Type or print legibly.
Sacramento, CA 95899-7413
(916) 322-8702
Provider Type (Check one.) (See last page of instructions for CCS program participation requirements by Provider Type and key to asterisk (*).)
Audiologist
Orthotist
Prosthetist
Respiratory Care Practitioner *
Dietitian
Pediatric Nurse Practitioner *
Psychologist
Social Worker
Occupational Therapist
Physical Therapist
Registered Nurse *
Speech/Language Pathologist
Other: ___________________
1. Legal name of applicant (last name)
(first name)
(middle initial)
2. Gender
Male
Female
3. Business address (office/hospital) (number, street)
City
County
State
ZIP code
4. Business telephone number
5. List active provider number(s) (see instructions)
6. Social security number (required if provider has no
active billing number registered with Medi-Cal)
(
)
7. Professional license, certification, or registration number (attach a copy)
Expiration date
8. Are you a member of a health care team providing multidisciplinary, multispecialty services in a hospital or outpatient department/clinic to children with
CCS-eligible medical conditions?
Yes
No
If yes, provide the following:
Name of hospital
City
State
Name of specialty clinic
Numbers 9 and 10—Complete these items according to your Provider Type. See the last page of instructions for CCS program
participation requirements.
A curriculum vitae (CV) may be attached to this application in lieu of filling in the information
requested. The CV
MUST
contain all the requested information.
9. Qualifying Professional and Post-Graduate Education
Professional School
State
Country
Degree Received
Graduation Date
10. Post-Graduate Training and Experience
Name of Institution
State
Country
Type of Training
From/To Dates
Internship
Residencies,
Preceptorships
(indicate clinical
or academic)
For State Use Only
Reviewed by
Date
Panel effective date
Page 1
DHCS 4515 (11/07)

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