Form Dhcs 4515 - California Children'S Services Program Individual Provider Paneling Application For Allied Health Care Professionals - Health And Human Services Agency Page 4
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6California Children’s Services (CCS) Program
Page 4
Individual Provider Paneling Application for
ALLIED HEALTH CARE PROFESSIONALS
INSTRUCTIONS FOR COMPLETING THE APPLICATION
For assistance, please call Children’s Medical Services Branch, Provider Services Unit
(916) 322-8702
The individual health care professionals listed under Provider Type on the first page of this application require paneling by the CCS program
and must complete this application in order to provide authorized services to CCS applicants or clients and bill the CCS program. This
application must also be completed when the individual health care professional is a rendering provider of a provider group.
Omission of any information or documentation on this application or the failure to appropriately sign this application may result in delays in or
inability to process this application. You may be contacted if additional information and documentation is needed.
Provider Type: Check the appropriate box that describes the profession for which you are applying to be paneled by the CCS program. A
separate application must be completed if you wish to be paneled under more than one profession/provider type except audiologists/hearing
aid dispensers (see number 12).
1. Legal name of applicant means the name under which the applicant is applying for paneling by the CCS program.
2. Check the appropriate box for the gender of the applicant.
3. Business address (office/hospital) means the office or hospital location where the applicant renders services, including the street name
and number, room or suite number or letter, city, county, state, and 5-digit ZIP code. A post office box or commercial box is not
acceptable.
4. Business telephone number means the primary business telephone number used at the applicant’s business address. A beeper number,
answering service, answering machine, pager, facsimile machine, or cellular phone is not acceptable as the business telephone number.
5. Provide your active provider number(s) if you are enrolled as a provider in the Medi-Cal program. Provide only the active
provider number(s) associated with the Provider Type for which this application is made
6. Provide the social security number of the individual named in number 1. This is only required if the provider does not have an active
billing number registered with Medi-Cal. Attach a clearly legible copy of the social security card if this number is being provided.
7. Provide your professional license, registration, certification number, or other approval to provide health care services and the expiration
date. Attach a clearly legible copy to the application.
8. Indicate Yes or No if you are working in a hospital outpatient department or clinic providing multidisciplinary, multispecialty health care
services to children with CCS-eligible medical conditions. If yes is indicated, provide the name, city, and state of the hospital and the
name of the specialty clinic in which you work.
For numbers 9 and 10, a CV may be attached to this application in lieu of filling in the information requested in these sections of the
application. However, the CV must contain all the requested information.
9. Provide your professional and post-graduate educational background. Refer to the last page of these instructions for the requirements
appropriate to your Provider Type. Indicate the name of the professional school, the state, country, degree received, and the graduation
date for each educational entry.
10. Provide your post-graduate training and experience. Indicate the name of the institution, state, country, type of training, specialty, and
from/to dates. Refer to the last page of these instructions for the requirements appropriate to your Provider Type.
11. Provide your employment history. Refer to the last page of these instructions for the requirements appropriate to your Provider Type.
Indicate the start and end dates, job title/classification, hours per week, total years/months worked, name of employer
(hospital/business), and city and state. Begin with the most recent job. IMPORTANT: Include the types of CCS-eligible medical
conditions of the clients to whom you have provided services and document experience with infants, children, and adolescents 0–21
years of age.
12. This item applies only to Audiologists. Indicate yes or no if you dispense hearing aids. If yes is checked, indicate yes or no if you want to
be considered for participation in the CCS program as an Audiologist and a Hearing Aid Dispenser (HAD). If yes is checked, provide
your HAD license number and expiration date. Attach a clearly legible copy of the HAD license to the application. Indicate yes or no if
you are located in a health care provider's office or facility in which audiological services are provided to children. If yes is checked,
provide the name of the office/facility, address, city, state, and ZIP code. Provide the age range of the children served.
13. This item applies only to Orthotists and Prosthetists. Provide the required documentation of experience as indicated for your Provider
Type located on the last page of these instructions.
SIGNATURE PAGE
Print the first name, middle initial, and last name of the individual indicated in number 1.
Signature of the applicant means the first name, middle initial, and last name of the individual indicated in number 1. An original signature
IN ANY COLOR OTHER THAN BLACK INK is required. Indicate the date the application is signed.
DHCS 4515 (11/07)
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