Form Dhcs 5023 - California Media Loan Request - Health And Human Services Agency
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1State of California—Health and Human Services Agency
Department of Health Care Services
Program Services Division – Resource Center
MS 2601
PO Box 997413
Sacramento, CA 95899-7413
California Department of Health Care Services
Resource Center Lending Services
1700 K Street, First Floor
Sacramento, CA 95811-4037
(800) 879-2772
FAX: (916) 323-1270
E-mail:
ResourceCenter@dhcs.ca.gov
Media Loan Request
Request Date: __________________________ Desired receipt date: ___________________
RUSH REQUEST JUSTIFICATION (for less than 2 weeks): ___________________________
___________________________________________________________________________
Requestor Name: __________________________ Telephone: (____) ___________________
Agency Name: _______________________________________________________________
Agency Address: ____________________________________________________________
City, State, Zip: ______________________________________________________________
Fax: (____) _____________________________________ Patron No. (if known)
Preferred title selections:
Media Format*:
1) _______________________________________________
DVD
VHS Lit. ** Other
2) _______________________________________________
DVD
VHS
Lit.
Other
Alternates if first choices are not available:
Media Format*:
1) _______________________________________________
DVD
VHS
Lit.
Other
2) _______________________________________________
DVD
VHS
Lit.
Other
3) _______________________________________________
DVD
VHS
Lit.
Other
* Please circle both DVD/VHS if you have no preference of format
**Literature
Please allow 1-2 weeks for delivery.
DHCS 5023 (06/13)
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Parent category: Legal