Form Dhcs 4514 - California Children'S Services (Ccs) Program Individual Provider Paneling Application For Physicians And Podiatrists - Health And Human Services Agency Page 2

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California Children’s Services (CCS) Program

Page 2

Individual Provider Paneling Application for

PHYSICIANS AND PODIATRISTS

I agree to:

Be enrolled as a provider in the Medi-Cal program with an active provider number.

B. Accept referrals, as my medical practice allows, of CCS applicants or clients who are Medi-Cal beneficiaries whose services are

authorized by the CCS program.

C. Abide by the laws, regulations, and policies of the Medi-Cal and CCS programs.

D. Request prior authorization for services from the CCS program.

Accept payment from the Medi-Cal or CCS programs for medically necessary services as payment in full.

F. Not submit a claim to, or demand or otherwise collect reimbursement from, the CCS applicant or client or persons acting on behalf of the

CCS applicant or client for any services authorized by the CCS program.

G. Obtain prior authorization (as applicable) from and bill the CCS applicant’s or client’s other health care coverage for services requested

from CCS prior to billing the Medi-Cal or CCS programs whenever such other health care coverage exists.

H. Provide timely copies of written documentation for CCS authorized services rendered as requested by the CCS program.

Serve CCS applicants and clients regardless of race, religion, age, sex, color, national origin, or physical or mental disability.

I hereby affirm that the information submitted on this application, and any attachments, are true, accurate, and complete to the best of my

knowledge and belief and is furnished in good faith.

Printed name of the applicant:

(First name)

(Middle initial) (Last name)

Date signed

Signature of the applicant in ANY COLOR OTHER THAN BLACK INK

(first, middle initial, last)

Privacy Statement

(Civil Code Section 1798 et seq.)

Any information provided will be used to verify eligibility to participate as a provider in the CCS program. Any information may also be provided to the State

Controller's Office, the California Department of Justice, the Department of Consumer Affairs, the Department of Corporations, or other state or local agencies

as appropriate, fiscal intermediaries, managed care plans, the Federal Bureau of Investigation, the Internal Revenue Service, Medicare fiscal intermediaries,

Health Care Financing Administration, Office of the Inspector General, and Medicaid and licensing programs in other states. For more information or access to

records containing your personal information maintained by this agency, contact the California Department of Health Care Services, CMS Branch, Provider

Services Unit, MS 8100, P.O. Box 997413, Sacramento, CA 95899-7413, (916) 322-8702.

Did you remember to enclose (as applicable):

Copy of Curriculum Vitae

Copy of American Board of Medical Specialties certificate(s) or letter verifying board eligibility, if not board certified

Copy of Professional License

Copy of Fellowship Completion Certificate (if applicable)

DHCS 4514 (11/07)