Form Dhcs 4517 - California Provider Electronic Data Interchange (Pedi) Account Request - Health And Human Services Agency Page 2

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State of California—Health and Human Services Agency
Department of Health Care Services
Children’s Medical Services (CMS) Branch
PEDI CONFIDENTIALITY OATH
As a condition of obtaining access to information concerning procedure or other data and records
utilized/maintained by the State Department of Health Services, I agree not to divulge any information obtained in
the course of my assigned duties to unauthorized person, and I agree not to publish or otherwise make public any
information regarding person(s) enrolled in the California Children’s Services (CCS) or Genetically Handicapped
Persons Program (GHPP) such that the persons who received such services are identifiable.
Access to such data shall be limited to state and federal personnel who require the information in the performance
of their duties, and to others such as providers and health care plans as may be authorized by the Department of
Health Services.
I recognize that unauthorized release of confidential information may be subject to civil and criminal sanctions
pursuant to the provisions of the Welfare and Institutions Code Section 14100.2.
Provider Facility/Plan Name:
Printed Name of Staff
Staff Signature
Date
DHCS 4517 (05/13)
Page 2 of 3

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