Form Dhcs 4512 - California Medical Eligiblity Data System Account Request - Health And Human Services Agency Page 3

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State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services (CMS) Branch
INSTRUCTIONS
County/Local Program:
The name of the county or local program submitting request.
Select One:
Add:
Select check box if this request is for account activation.
Delete:
Select check box if this request is for account deactivation.
Name (Last, First):
Type user’s last name, then user’s first name.
Email Address:
Type user’s email address.
Phone:
Type user’s phone number, including area code (and extension if applicable) in format
(999)999-9999.
Last 4 Digits of SSN:
Type the last four digits of the user’s Social Security Number (SSN).
Address:
Type the work address of the users listed above. Include number, street, suite number,
city or town, state, and ZIP code. If more than one location, list the primary work address
of the office or use a different form for each address.
Type the name of the person submitting request. Representative must be a State CMS
Representative’s Name (Print):
Branch manager, California Children’s Services (CCS)/CMS Administrator, Child Health
and Disability Program (CHDP) Director, CHDP Deputy Director.
Phone:
Type the representative’s phone number, including area code (and extension if
applicable) in format (999)999-9999.
Representative’s Name (Signature): Signature of representative.
Date:
Date account request was signed by the representative.
County/Local Program:
The name of the county or local program submitting request.
Printed Name of Staff:
Name of user with the “Add” option selected. Each user with the “Add” option selected
must be listed and sign the confidentiality oath.
Staff Signature:
Signature of user with the “Add” option selected. Each user with the “Add” option selected
must be listed and sign the confidentiality oath.
Date:
Date user with “Add” option selected signed the form.
DHCS 4512 (Rev 05/13)
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