Form Dhcs 4515 - California Children'S Services Program Individual Provider Paneling Application For Allied Health Care Professionals - Health And Human Services Agency Page 6

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California Children’s Services (CCS) Program

Page 6

Individual Provider Paneling Application for

ALLIED HEALTH CARE PROFESSIONALS

Prosthetists

A prosthetist must meet all of the following requirements:

Be certified by the American Board for Certification in Orthotics and Prosthetics or the Board for Orthotist/Prosthetist Certification; and

2. Submit a letter from a CCS-paneled physician specializing in physical medicine and rehabilitation or orthopedics that documents the

prosthetist’s experience providing orthotics to infants, children, or adolescents with a CCS-eligible medical condition.

Psychologists

Psychologists must be:

Licensed by the California Board of Psychology; and

Have a minimum of two years of experience which shall include counseling or testing children with special health care needs.

3. Individuals who are licensed as an educational psychologist by the California Board of Behavioral Sciences may be considered for

participation in the CCS program as a psychologist. Such individuals shall also possess the experience specified in this section.

*Registered Nurses (RNs)

1. Participation in the CCS program as an RN is limited to serving as a designated core member of a multidisciplinary, multispecialty team

in an outpatient department or clinic of an acute care hospital providing services to children with CCS-eligible medical conditions.

An RN must meet all of the following requirements:

Be licensed by the California Board of Registered Nursing;

b. Have a minimum preparation of a baccalaureate degree in nursing from a program having requirements equal to or greater than a

baccalaureate level nursing program approved by the California Board of Registered Nursing;

Have a minimum of two years of clinical nursing experience of which one year shall be in pediatrics; and

d. Currently be a designated core member of a multidisciplinary, multispecialty team as specified in 1. The RN’s responsibilities in the

outpatient clinic must include nursing assessment and intervention related to the implementation of the team care plan for outpatient

services such as coordination of the patient’s care between hospitalizations, community services, and team conferences.

Responsibilities related to routine outpatient care are not valid for meeting the requirements of this section. Routine outpatient care

must include, but not be limited to, regularly scheduled blood draws, monitoring of vital signs, administration of medication and

scheduling return appointments.

*Respiratory Care Practitioners (RCPs)

1. Participation in the CCS program as a respiratory care practitioner shall be limited to serving as a designated core member of a

multidisciplinary, multispecialty team in an outpatient department or clinic of an acute care hospital providing services to children with

CCS-eligible medical conditions.

An RCP must meet all of the following requirements:

Be licensed by the Respiratory Care Board of California;

Have a current Registered Respiratory Therapist credential issued by the National Board for Respiratory Care;

Have a minimum of two years of respiratory care experience of which one year shall be in pediatrics; and

c. Currently be a designated core member of a multidisciplinary, multispecialty team as specified in 1 and have responsibilities in the

outpatient clinic that include individualized diagnostic and therapeutic respiratory care procedures, and patient education, related to

the implementation of the team care plan for outpatient services.

An RCP may also be referred to as a respiratory therapist or inhalation therapist.

Social Workers

Social workers must:

Be licensed as a clinical social worker by the California Board of Behavioral Sciences; or

b. Have a master’s degree in social work from a school accredited by the Council on Social Work Education and five years of fulltime

social work experience that shall include providing social work services to children with CCS-eligible medical conditions and their

families.

Individuals who have less than the required five years of experience specified in 1b of this section shall submit either of the following:

A certificate from the California Board of Behavioral Sciences verifying registration as an Associate Clinical Social Worker; or

b. A written letter on the letterhead of the individual’s employer, signed by the individual’s supervisor or social work department director

and containing verification of all of the following requirements:

(1) That the individual shall receive weekly supervision if he or she has less than two years of post-master’s degree experience

providing social work services.

(2) That the individual shall receive monthly supervision if he or she has at least two years of post-master’s degree experience but

less than the required five years of experience specified in 1b of this section.

3. Supervision of the work of the individual specified in 2 of this section shall be provided by a social worker who meets the requirements of

1a or 1b of this section.

Speech-Language Pathologists

Speech/language pathologists must be licensed by the California Speech/Language Pathology and Audiology Board (CSLPAB) and have two

years of clinical experience providing speech/language pathology services, one year of which must have been with infants, children, or

adolescents with CCS-eligible medical conditions. The experience may include the supervised Required Professional Experience (RPE) for

licensure by the CSLPAB as specified in Business and Professions Code, Section 2532.2(d).

Other

Provider Types not listed require professional and/or business licensure, certification, registration, or other approval to provide health care services.

DHCS 4515 (11/07)