Form Dhs 4448 (11/04) - Application For Certification As A Comprehensive Perinatal Services Program Provider Page 4

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5. Please indicate to what extent the applicant or staff have received state-approved training in the provision of the Comprehensive Peritatal Services Program:

Staff person(s): _______________________________________________________

Date:____________________________________

Location of training: _________________________________________________________

If you have not yet participated in such training, indicate whom and when you intend to: _____________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________

6. Please attach and label the following requested documents in the order they are described:

Prenatal Medical Record form(s): Attach a blank sample prenatal medical records form(s).

II.

Individualized Care Plan: Includes obstetric, nutrition, psychosocial, and health education components.

III.

Nutrition, Psychosocial, and Health Education Assessment Tools: Nutrition, psychosocial, and health education documents for initial assessment, trimester, reassessments, and postpartum assessments.

IV.

General Description of Practice: A description as to how the practice, clinic, and/or organization will provide CPSP services for the obstetric, nutrition, psychosocial, and health education components.

Delivery Hospitals: The name(s) and address(es) of the hospital(s) at which deliveries are planned to take place.

VI. Referral Services: The names and addresses of the persons and agencies to whom you will refer for OB and non-OB care; well-child pediatric care (e.g., CHDP); family planning services, Supplemental Nutrition Program for

Women, Infants, and Children (WIC) services; genetic services; and dental services.

VII. Antepartum/Intrapartum/Postpartum Agreements: If a person or entity other than the applicant will be responsible for performing and for billing, antepartum and/or intrapartum and/or postpartum obstetrical care, the applicant

must attach a written agreement(s) to this application. The agreement(s) must describe the relationship and specific responsibilities of the applicant and the obstetric care provider(s), including the flow of patient services and

patient information between all providers. It should include, as well, the name(s) of the delivery hospital(s) where obstetric provider has privileges, how emergency services will be provided, and billing responsibilities.

7. Please give approximate number of total deliveries _______________ and Medi-Cal deliveries ______________ by the applicant for the last 12 months.

Please furnish any other information that you feel would help evaluate your application to become approved as a Comprehensive Perinatal Service Program provider in the Department of Health Services’ Medi-Cal program.

____________________________________________________________________________________________________________________________________________________________________

I certify under penalty of perjury that the above information is true, accurate, and complete to the best of my knowledge. I understand that incorrect or inaccurate

information may affect my eligibililty to receive Medi-Cal reimbursement and that I must report changes to the above information to the local CPSP coordinator.

________________________________________________________________

_________________________________________________________________________________

Authorized agent’s name (please print or type)

Title (please print or type)

________________________________________________________________

_________________________________________________________________________________

Authorized agent’s original signature

Date

All information submitted with this application will be part of a file that is open for public inspection pursuant to the California Public Records Act, Government Code, Section 6250 ET SEQ.

FOR OFFICIAL USE ONLY

Actions taken on application:

Recommended disposition to DHS:

Returned for additional information

_______

________________

To approve

Not to approve

Initial

Date

Application resubmitted

_______