Form DHCS1739 "Mental Health Professional Licensing Waiver Request" - California

What Is Form DHCS1739?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2013;
  • 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;

Download a fillable version of Form DHCS1739 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 DHCS1739 "Mental Health Professional Licensing Waiver Request" - California

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State of California – Health and Human Services Agency
Department of Health Care Services
(Please fill-in all boxes below. See reverse side for completion instructions.)
(Include aliases and maiden names):
WITHIN CALIFORNIA/NOT LICENSE ELIGIBLE
OUT-OF-STATE/LICENSING-EXAMINATION-READY:
PSYCHOLOGIST:
(3-year waiver maximum)
(5-year waiver maximum)
PSYCHOLOGIST
LCSW
LMFT
LPCC
(SIGNATURE----MENTAL HEALTH DIRECTOR/DESIGNEE)
FOR STATE DEPARTMENT OF HEALTH CARE SERVICES, MENTAL HEALTH SERVICES DIVISION USE ONLY.
DO NOT COMPLETE BELOW
Approved By:
Title:
Date:
Signature:
This waiver is granted pursuant to Welfare and Institutions Code Section 5751.2 and with the stipulation that the
employer and the applicant assume responsibility for meeting all applicable statutory and regulatory requirements
during the approved waiver period.
DHCS 1739 (06/2013)
Page 1 of 2
State of California – Health and Human Services Agency
Department of Health Care Services
(Please fill-in all boxes below. See reverse side for completion instructions.)
(Include aliases and maiden names):
WITHIN CALIFORNIA/NOT LICENSE ELIGIBLE
OUT-OF-STATE/LICENSING-EXAMINATION-READY:
PSYCHOLOGIST:
(3-year waiver maximum)
(5-year waiver maximum)
PSYCHOLOGIST
LCSW
LMFT
LPCC
(SIGNATURE----MENTAL HEALTH DIRECTOR/DESIGNEE)
FOR STATE DEPARTMENT OF HEALTH CARE SERVICES, MENTAL HEALTH SERVICES DIVISION USE ONLY.
DO NOT COMPLETE BELOW
Approved By:
Title:
Date:
Signature:
This waiver is granted pursuant to Welfare and Institutions Code Section 5751.2 and with the stipulation that the
employer and the applicant assume responsibility for meeting all applicable statutory and regulatory requirements
during the approved waiver period.
DHCS 1739 (06/2013)
Page 1 of 2
State of California – Health and Human Services Agency
Department of Health Care Services
MENTAL HEALTH PROFESSIONAL LICENSING WAIVER REQUEST
Instructions For Completing This Form
1)
Applicant’s Full Name, Including Aliases and Maiden Names: DHCS staff need this information, when
applicable, to track accurately the applicant’s waiver history.
2)
Type of Waiver Request: Clearly indicate the type of waiver request. To be eligible for the Out-of-
State/License-Ready category, an applicant must be both license-ready (i.e., have accrued the number of
hours of supervised professional experience required to sit for the licensing examination) and have been
recruited from out-of-State. When submitting an application for an Out-of-State/License Ready waiver, the
MHP must submit a letter from the appropriate licensing board which states that the applicant has sufficient
experience to gain admission to the licensing examination.
3)
Employment Start Date (In the Position Requiring the Waiver): Specify the date the applicant will start
employment in the position requiring a waiver.
In order for DHCS to determine if the applicant has been previously employed in a position requiring a
waiver, it is necessary to attach a copy of the applicant’s post-degree employment history. This can take the
form of a current, complete resume or recent employment application.
4)
Request Submitted By (Mental Health Director/Designee): All waiver requests must be submitted, signed
and dated by the local county mental health director or the director’s designee.
For additional information on the professional licensing waiver process, see DMH Letter No 10-03.
DHCS 1739 (06/2013)
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