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Form Dhcs 5101 - California Dhcs Internal Employee Only Caloms Tx Itws Approver Form - Health And Human Services Agency

State of California — Health and Human Services Agency

Department of Health Care Services

CalOMS

MS 2603

PO Box 997413

Sacramento, CA 95899-7413

DHCS Internal Employee Only

DHCS Approved

CalOMS Tx ITWS Approver Form

Date

Approver

For Granting Access to the CalOMS Treatment Data System

DHCS Office/Unit Name:

To ensure the confidentiality of CalOMS Treatment data, the Department of Health Care Services (DHCS) requests the appropriate

DHCS Office director to designate a primary and a secondary contact to be responsible for approving DHCS office employee requests

for access to confidential patient data in the CalOMS Treatment data system. Please complete and fax this form to DHCS at (916)

322-7117. If you have questions about this form, please call (916) 327-3010 or e-mail CalOMSHelp@DHCS.ca.gov.

Please print all information

Primary Approver:

First Name:

Last Name:

Title:

Phone Number: (

)

Fax Number: : (

)

Email Address:

Primary Approver’s Signature:

(Signer acknowledges having read the Confidentiality Statement for all AOD Patient Data.)

Secondary Approver:

First Name:

Last Name:

Title:

Phone Number: (

)

Fax Number: : (

)

Email Address:

Secondary Approver’s Signature:

(Signer acknowledges having read the Confidentiality Statement for all AOD Patient Data.)

DHCS DMSS Approval:

I hereby designate the above-named individuals to have independent authority to approve access requests to specific confidential

CalOMS Treatment data. The DHCS may rely on approvals, denials, and changes made by these individuals in its processing of

access requests to the above selected system(s). As changes occur to the above approving contact’s information (name, phone, e-mail

or system), I will sign an updated certification and fax it to the appropriate fax numbers listed above. Also, I acknowledge reading the

Confidentiality Statement for all AOD Patient Data.

_________________________________________________________________

IT Director

(signed and printed)

Date

DHCS 5101 (06/13)

ADP 100179 (06/13)

Form Dhcs 5101 - California Dhcs Internal Employee Only Caloms Tx Itws Approver Form - Health And Human Services Agency

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