Form Dhcs 9093 - Cms Net County System Administrator Security And Confidentiality Oath
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1
2State of California – Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services (CMS) Branch
Submit Form: Fax: (916) 440-5346 or
CMS NET COUNTY SYSTEM ADMINISTRATOR
Scan and email:
cmshelp@dhcs.ca.gov
SECURITY AND CONFIDENTIALITY OATH
Contact the CMS Net Help Desk
Questions?
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This form is to add a CMS Net user as a County System Administrator or County System Administrator Plus. Please
type or print legibly.
County:
Mark one type of access- County System Administrator or County System Administrator Plus.
_____ County System Administrator
1. Add, deactivate or reactivate users
2. Reset user passwords
3. Modify/assign user security profiles
4. Modify/Reauthorize Cancelled SAR
5. Modify historical referral/transfer dates
6. Edit permanently assigned case numbers
7. End date Healthy Families Plans
_____ County System Administrator Plus
All above County System Administrator capabilities plus:
8. Correct program eligibility dates
9. Correct client eligibility closures/denials
10. Access transaction tracking to determine who last updated a particular record
Read the agreement items listed below and sign your initials if you agree to each.
_____ I will not divulge or share in any users’ personal information including, but not limited to passwords and
access codes to individuals who are not a designated CMS State or County System administrators.
_____ I will not abuse or misuse the privileges as a County System administrator.
_____ I will not create any unnecessary user security profiles such as fake, generic, or pseudo accounts.
_____ I understand that the Department of Health Care Services, Children’s Medical Services Branch has the
right to remove and revoke users’ and counties’ access to have County System administrator privileges
at any time for any or no reason at all.
_____ I will follow and adhere to the CMS User Security procedures and guidelines for County System
administrators outlined above.
Applicant’s Name (Last, First):
Title:
Email Address:
Phone:
Date:
Applicant’s Name (Signature):
Phone:
Representative’s Name (Print):
Date:
Representative’s Name (Signature):
DHCS 9093 (Rev 05/13)
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