Form Dhcs 4512 - California Medical Eligiblity Data System Account Request - Health And Human Services Agency

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State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services (CMS) Branch
Fax: (916) 440-5346 or
Submit Form:
MEDI-CAL ELIGIBLITY DATA SYSTEM (MEDS)
Scan and email:
cmshelp@dhcs.ca.gov
ACCOUNT REQUEST
Contact the CMS Net Help Desk
Questions?
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This form is to request MEDS access activation or deletion for State, county and local program staff supported by
the CMS Branch. When the “Add” option is selected the user will be assigned a new User ID and temporary
password. The form is also to be used to request deactivation of a user’s MEDS ID. Please type or print legibly and
allow one week for processing new requests.
County/Local Program:
Last 4
Select
Phone
Name (Last, First)
Email Address
digits of
One
(999)999-9999
SSN
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Add
Delete
Address:
Phone:
Representative’s Name (Print):
Date:
Representative’s Name (Signature):
DHCS 4512 (Rev 05/13)
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