Form Dhcs 5054 - California Notice Of Inspection Of Confidential Records - Health And Human Services Agency

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State of California — Health and Human Services Agency
Department of Health Care Services
Licensing and Certification Division
MS 2600
PO Box 997413
Sacramento, CA 95899-7413
NOTICE OF INSPECTION OF CONFIDENTIAL RECORDS
The Department of Health Care Services (DHCS) hereby acknowledges the
confidentiality of participant and personnel records maintained by any alcoholism or
drug abuse recovery or treatment facility, or other program providing services as
stipulated in 42 CFR (Code of Federal Regulations), Part 2 and the Health Insurance
Portability and Accountability Act of 1996 (“HIPAA”), 45 CFR Part 160 & 164.
Inspection of participant and personnel records will be performed by the Department’s
duly authorized representative to determine compliance with Alcohol and/or Other Drug
Program Certification Standards and/or applicable licensing regulations. No record of
resident identifying information will be made or retained by the authorized
representative for the Department in connection with the inspection without the
program/licensee being properly notified in accordance with the above referenced
federal regulations.
_____________________________________________________________________
Facility Name
DHCS License/Certification Number
_________________________________
________________________________
DHCS Representative
Date
Licensee/Designee
Date
(I acknowledge receiving the original of this form.)
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For energy saving tips, visit the Flex Your Power website at
DHCS 5054 (06/13)

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