Form Dhcs 4514 - California Children'S Services (Ccs) Program Individual Provider Paneling Application For Physicians And Podiatrists - Health And Human Services Agency
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1
2
3
4Department of Health Care Services
State of California—Health and Human Services Agency
California Children’s Services (CCS) Program
INDIVIDUAL PROVIDER PANELING APPLICATION FOR
PHYSICIANS AND PODIATRISTS
Return completed form to:
Department of Health Care Services
Children’s Medical Services Branch
IMPORTANT:
•
Provider Services Unit
Fields 1–10 are mandatory and must be completed; enter N/A if not applicable.
MS 8100
•
See attached instructions to complete this form.
P.O. Box 997413
•
Type or print legibly.
Sacramento, CA 95899-7413
(916) 322-8702
Provider Type (Check one.) (See last page of instructions for CCS program participation requirements by Provider Type.)
Physician
Podiatrist
1. Legal name of applicant (last name)
(first name)
(middle initial)
2. Gender
Male
Female
3. Business address (office/hospital) (number, street)
City
County
State
ZIP code
Provider number
Professional license number (a
4. Business telephone number
5.
6.
ttach a copy)
Expiration date
(
)
7.
a.
b.
c.
d.
Currently Practicing
Name of Issuing Board(s)
Board
Board
Attach a copy of each board certificate. If board eligible,
Specialty(s)
Yes
No
Certified
Eligible
attach a copy of board eligibility documentation.
8.
a.
b.
c.
d.
Currently Practicing
Name of Issuing Board(s)
Board
Board
Attach a copy of each board certificate. If board eligible,
Subspecialty(s)
Yes
No
Certified
Eligible
attach a copy of board eligibility documentation.
9. Additional Subspecialty and/or Pediatric Subspecialty Training
a.
c.
b.
d.
Indicate any additional fellowship or pediatric fellowship training or experience for your subspecialty that does not currently have a
certificate issued by the American Board of Medical Specialties, e.g., Ophthalmology, Cornea and External Disease, Pediatric
Anesthesiology. Attach a copy of fellowship completion certificate.
10. Specify the hospital(s) where you have active admitting privileges. If you do not have active admitting privileges, list the health plan(s)
in which you are currently credentialed and enrolled. Attach an additional sheet if necessary and label as number 10.
Name of Hospital/Health Plan
City
11. This item applies only to Family Practice Physicians and Podiatrists. Submit documentation of experience. (See last page of
instructions for CCS program participation requirements for your provider type.)
For State Use Only
Reviewed by
Date
Panel effective date
Page 1
DHCS 4514 (11/07)
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