Form DHCS8049 "County Attestation to Compliance With Drug Medi-Cal Postservice Prepayment and Postservice Postpayment(Pspp) Corrective Action Plan" - California

What Is Form DHCS8049?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on February 1, 2021;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS8049 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS8049 "County Attestation to Compliance With Drug Medi-Cal Postservice Prepayment and Postservice Postpayment(Pspp) Corrective Action Plan" - California

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State of California
Health and Human Services Agency
Department of Health Care Services
COUNTY ATTESTATION TO COMPLIANCE
WITH DRUG MEDI-CAL POSTSERVICE PREPAYMENT AND
POSTSERVICE POSTPAYMENT(PSPP)
CORRECTIVE ACTION PLAN
(Form used for both DMC-ODS and DMC State Plan counties)
The Contractor shall monitor and attest completion by providers with CAP requirements
as required by any PSPP reviews. The Contractor shall attest to DHCS, using the
County Attestation to Compliance DHCS Form 8049, that the corrective actions in the
CAP have been completed by the provider. Submission of DHCS Form 8049 by
Contractor must be completed within the timeline specified in the approved CAP, as
noted by DHCS.
I hereby attest that
, DMC #
, has fully implemented
(Provider Name)
(Provider #)
all corrective actions in the PSPP Report issued on
.
(Date of PSPP Report)
Print Name
Title
Signature
Date
Phone
E-Mail
Agency
County
Please submit DMC-ODS Wavier form to:
SudCountyReports@dhcs.ca.gov
Please submit DMC State Plan form to:
MCBHDMonitoring@dhcs.ca.gov
DHCS 8049 (Revised 02/2021)
State of California
Health and Human Services Agency
Department of Health Care Services
COUNTY ATTESTATION TO COMPLIANCE
WITH DRUG MEDI-CAL POSTSERVICE PREPAYMENT AND
POSTSERVICE POSTPAYMENT(PSPP)
CORRECTIVE ACTION PLAN
(Form used for both DMC-ODS and DMC State Plan counties)
The Contractor shall monitor and attest completion by providers with CAP requirements
as required by any PSPP reviews. The Contractor shall attest to DHCS, using the
County Attestation to Compliance DHCS Form 8049, that the corrective actions in the
CAP have been completed by the provider. Submission of DHCS Form 8049 by
Contractor must be completed within the timeline specified in the approved CAP, as
noted by DHCS.
I hereby attest that
, DMC #
, has fully implemented
(Provider Name)
(Provider #)
all corrective actions in the PSPP Report issued on
.
(Date of PSPP Report)
Print Name
Title
Signature
Date
Phone
E-Mail
Agency
County
Please submit DMC-ODS Wavier form to:
SudCountyReports@dhcs.ca.gov
Please submit DMC State Plan form to:
MCBHDMonitoring@dhcs.ca.gov
DHCS 8049 (Revised 02/2021)