Form MC5400 "Application for Certification of Special Treatment Program Services" - California

What Is Form MC5400?

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 May 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 MC5400 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 MC5400 "Application for Certification of Special Treatment Program Services" - California

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State of California-Health and Human Services Agency
Department of Health Care Services
APPLICATION FOR CERTIFICATION OF
SPECIAL TREATMENT PROGRAM SERVICES
INITIAL
RENEWAL
INSTRUCTIONS: Attach this form with the facility’s written program plan
Please send application to: Department of Health Care Services
Mental Health Services Division
Program Certification Unit
1500 Capitol Ave. MS 2703
Sacramento, CA 95814
APPLICANT (s) NAME AND ADDRESS
TELEPHONE
FACILITY NAME AND ADDRESS
TELEPHONE
FACILITY MAILING ADDRESS ( if different )
Person in Charge of Facility (include title)
Maximum bed
Capacity
PATIENT TYPE
AGE RANGE OF CLIENTS
Number of Certified STP Beds
NAME OF PROGRAM DIRECTOR
DISCIPLINE
DEGREE
YEARS WORKED WITH
MENALLY DISABLED
INTERDISCIPLINARY PROFESSIONAL STAFF
ADMINISTRATOR’S SIGNATURE:
DATE
FACILITY FAX:
EMAIL ADDRESS:
MC 5400 (05/2013)
State of California-Health and Human Services Agency
Department of Health Care Services
APPLICATION FOR CERTIFICATION OF
SPECIAL TREATMENT PROGRAM SERVICES
INITIAL
RENEWAL
INSTRUCTIONS: Attach this form with the facility’s written program plan
Please send application to: Department of Health Care Services
Mental Health Services Division
Program Certification Unit
1500 Capitol Ave. MS 2703
Sacramento, CA 95814
APPLICANT (s) NAME AND ADDRESS
TELEPHONE
FACILITY NAME AND ADDRESS
TELEPHONE
FACILITY MAILING ADDRESS ( if different )
Person in Charge of Facility (include title)
Maximum bed
Capacity
PATIENT TYPE
AGE RANGE OF CLIENTS
Number of Certified STP Beds
NAME OF PROGRAM DIRECTOR
DISCIPLINE
DEGREE
YEARS WORKED WITH
MENALLY DISABLED
INTERDISCIPLINARY PROFESSIONAL STAFF
ADMINISTRATOR’S SIGNATURE:
DATE
FACILITY FAX:
EMAIL ADDRESS:
MC 5400 (05/2013)