Form Dhs 4448 (11/04) - Application For Certification As A Comprehensive Perinatal Services Program Provider Page 2

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4. Comprehensive Perinatal Services Practitioners:
* Practitioner Types
** Years of Experience
Physician
(MD)
Marriage and Family Therapist
(MFT)
For MD, CNM, RN, NP, PA, SW, MFCC, HE, LVN—Years of experience in Maternal and Child Health.
Certified Nurse Midwife
(CNM)
Health Educator
(HE)
For CE, CPHW—Years of experience in perinatal care.
Registered Nurse
(RN)
Childbirth Educator
(CE)
For RD/RDE—Years of experience in perinatal nutrition.
Nurse Practitioner
(NP)
Dietitian/Registered
(RD)
Physician Assistant
(PA)
Comprehensive Perinatal Health Worker
(CPHW)
Social Worker
(SW)
Licensed Vocational Nurse
(LVN)
Please identify all program practitioners who will be providing Comprehensive Perinatal Services (Obstetric and Support Services).
If any services are provided at site(s) different from service address specified on page 1, please indicate location and services.
Practitioners:
Last Name
First
Middle
CA License,
Expr. Date of
Medi-Cal
Initial
Certificate,
Lic., Cert., or
Year Graduated
Rendering
* Type or
Registration
Reg. No.
Degree and
Provider
** Years of
Location
Specialty
Number
MM/DD/YY
Institution/Univ.
Number
Experience
Page 2 of 4
DHS 4448 (11/04)

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