Form Dhcs 4515 - California Children'S Services Program Individual Provider Paneling Application For Allied Health Care Professionals - Health And Human Services Agency Page 3

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California Children’s Services (CCS) Program

Page 3

Individual Provider Paneling Application for

ALLIED HEALTH CARE PROFESSIONALS

I agree to:

Be enrolled as a provider in the Medi-Cal program with an active provider number.

B. Accept referrals, as my practice allows, of CCS applicants or clients who are Medi-Cal beneficiaries whose services are authorized by

the CCS program.

C. Abide by the laws, regulations, and policies of the Medi-Cal and CCS programs.

D. Request prior authorization for services from the CCS program.

Accept payment from the Medi-Cal or CCS programs for medically necessary services as payment in full.

F. Not submit a claim to, or demand or otherwise collect reimbursement from, the CCS applicant or client or persons acting on behalf of the

CCS applicant or client for any services authorized by the CCS program.

G. Obtain prior authorization (as applicable) from and bill the CCS applicant's or client's other health care coverage for services requested

from CCS prior to billing the Medi-Cal or CCS programs whenever such other health care coverage exists.

H. Provide timely copies of written documentation for CCS authorized services rendered as requested by the CCS program.

Serve CCS applicants and clients regardless of race, religion, age, sex, color, national origin, or physical or mental disability.

I hereby affirm that the information submitted on this application, and any attachments, is true, accurate, and complete to the best of my

knowledge and belief and is furnished in good faith.

Printed name of applicant (first, middle, last)

Signature of applicant in other than black ink

Date

Privacy Statement

(Civil Code Section 1798 et seq.)

Any information may also be provided to the State Controller’s Office, the California Department of Justice, the Department of Consumer Affairs, the

Department of Corporations, or other state or local agencies as appropriate, fiscal intermediaries, managed care plans, the Federal Bureau of Investigation, the

Internal Revenue Service, Medicare fiscal intermediaries, Center for Medicare and Medicaid Services, Office of the Inspector General, and Medicaid and

licensing programs in other states. For more information or access to records containing your personal information maintained by this agency, contact the

California Department of Health Care Services, CMS Branch, Provider Services Unit, MS 8100, P.O. Box 997413, Sacramento, CA 95899-7413, (916) 322-8702.

Did you remember to enclose (as applicable):

Copy of social security card (required only if provider does not have an active Medi-Cal number).

Copy of professional license, registration, certification or other approval.

Letter required for social worker applicants.

Letter required for orthotist or prosthetist applicants.

DHCS 4515 (11/07)