State of California—Health and Human Services Agency
Department of Health Services
M
C
H
B
ATERNAL AND
HILD
EALTH
RANCH
For Official Use Only
Local Agency Control Number___________________ Date Received ____________
APPLICATION FOR CERTIFICATION AS A COMPREHENSIVE
PERINATAL SERVICES PROGRAM (CPSP) PROVIDER
State Control Number _________________________ Date Received ____________
Please read all the attached materials thoroughly before completing this form and retain a copy for your records. Please type or print in black ink. When completed,
the original application form should be mailed with one copy to your local Comprehensive Perinatal Services Program Coordinator.
1. Name of Applicant (Name must be the same name used for current Medi-Cal provider number.)
Telephone Number
(
)
Other Name (if any used for provider services)
Fax Number
(
)
Service Address (number/street)
Billing Address (number/street)
City
State
ZIP Code
City
State
ZIP Code
Contact Person
Telephone Number
Contact Person
Telephone Number
(
)
(
)
E-mail Address
E-mail Address
2. Please check provider type which applies to this application. The CPSP provider must be a:
General practice physician
Family practice physician
Family nurse practitioner
Obstetrician/gynecologist
Pediatric nurse practitioner
Pediatrician
Preferred provider organization
Clinic
Hospital
Alternative birthing center
Certified nurse midwife
Group (any one of whose members is general or family
practice,
OB/GYN, or pediatrician)
3. Are you a current Medi-Cal provider?
Current Medi-Cal provider number for application*
Yes
No
If no, do not complete the rest of this form. Contact your local CPSP coordinator.
* Current Medi-Cal provider number to be used by the applicant at the service address. Separate applications must be completed for each site that has a separate Medi-Cal provider number. If you are
applying as an alternative birthing center, please contact your local CPSP coordinator for special instructions.
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DHS 4448 (11/04)