Form Dhcs 4514 - California Children'S Services (Ccs) Program Individual Provider Paneling Application For Physicians And Podiatrists - Health And Human Services Agency Page 4
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4California Children’s Services (CCS) Program
Page 4
Individual Provider Paneling Application for
PHYSICIANS AND PODIATRISTS
CCS PROGRAM PARTICIPATION REQUIREMENTS
BY PROVIDER TYPE
Physicians
1.
Physicians must be:
a.
Licensed as a physician and surgeon by the Medical Board of California or by the Osteopathic Medical Board of California; and
b.
Certified by a member board of the American Board of Medical Specialties or the Bureau of Osteopathic Specialists.
c. Physicians who are not board certified but who are eligible for the certifying examination may participate in the CCS program for not
more than three years. A verification letter of eligibility from the applicable member board is required. If the physician does not have
a board verification letter, he or she shall submit other evidence regarding eligibility to take the board examination such as a letter
from the Medical Director of his or her residency program verifying satisfactory completion of training.
2. Family practice physicians must meet the requirements of number 1 above and have documented experience treating children with CCS
eligible medical conditions for at least five years, or have treated 100 or more such children.
Documented experience means providing the CCS program with a list of cases indicated by a numeric value instead of a name, their
CCS-eligible medical condition and the range of dates during which services were rendered. Do not provide the names of the children or
any other specific identifiers in your report.
Podiatrists
Podiatrists must meet all of the following requirements:
1.
Be licensed to practice podiatric medicine by the California Board of Podiatric Medicine;
2.
Be certified by the American Board of Podiatric Surgery or the American Board of Podiatric Orthopedics; and
3. Have documented experience treating children with CCS-eligible medical conditions for at least five years, or have treated 100 or more
such children.
Documented experience means providing the CCS program with a list of cases indicated by a numeric value instead of a name, their
CCS eligible medical condition, and the range of dates during which services were rendered. Do not provide the names of the children
or any other specific identifiers in your report.
DHCS 4514 (11/07)
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