Form Dhcs 4515 - California Children'S Services Program Individual Provider Paneling Application For Allied Health Care Professionals - Health And Human Services Agency Page 2

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California Children’s Services (CCS) Program
Page 2
Individual Provider Paneling Application for
ALLIED HEALTH CARE PROFESSIONALS
11. Employment History (Begin with most recent job.)
Start date
Total worked (years/months) Name of hospital/business, including city and state
Hours per week
Total worked (years/months)
Duties performed—Include the types of medical conditions of the clients to whom you have provided services
Start date
Total worked (years/months) Name of hospital/business, including city and state
Hours per week
Total worked (years/months)
Duties performed—Include the types of medical conditions of the clients to whom you have provided services
12. This item applies only to Audiologists. Complete all items as indicated.
Yes
No
a.
Do you dispense hearing aids? If yes, complete 12b; if no, skip to 12c.
Yes
No
b.
Do you want to be considered for participation in the CCS program as an audiologist and a hearing aid
dispenser?
If yes, provide hearing aid license number and expiration date:________________________ (attach copy)
This application will be used for both provider types.
Yes
No
c.
Are you located in a health care provider office or facility in which audiological services are provided to
children? If yes, provide the following information:
Name of office/facility
Address (number, street)
City
State
ZIP code
Age of children served
All ages
Age range (specify): ___________________________________________
13. This item applies only to Orthotists and Prosthetists. Submit documentation of experience. (See the last page of instructions for CCS
program participation requirements for your Provider Type.)
DHCS 4515 (11/07)

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