Form DHCS5100 "Caloms Tx Itws Vendor Approver Form for Granting Access to the Caloms Treatment Data System" - California

What Is Form DHCS5100?

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;
  • Fill out the form in our online filing application.

Download a printable version of Form DHCS5100 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 DHCS5100 "Caloms Tx Itws Vendor Approver Form for Granting Access to the Caloms Treatment Data System" - California

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State of California — Health and Human Services Agency
Department of Health Care Services
CalOMS
MS 2603
PO Box 997413
Sacramento, CA 95899-7413
CalOMS Tx ITWS Vendor Approver Form
DHCS Approved
Date
Approver
For Granting Access to the CalOMS Treatment Data System
Vendor (System) Name:
To ensure the confidentiality of county/direct provider CalOMS Treatment data, the Department of Health Care Services (DHCS)
requires that each designated vendor identify a primary and a secondary contact to be responsible for approving requests for ITWS
access to confidential county/direct provider confidential patient data in the CalOMS Treatment data system. Please complete and fax
this form to DHCS at (916) 322-7117. If you have questions about this form, please call (916) 327-3010 or e-mail
CalOMSHelp@DHCS.ca.gov.
Please print all information
Primary Vendor (User):
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: (
)
Email Address:
Primary Approver’s Signature:
(Signer acknowledges having read the Confidentiality Statement to Users of the Information Technology Web Services (ITWS).)
Secondary Vendor (User):
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: (
)
Email Address:
Secondary Approver’s Signature:
(Signer acknowledges having read the Confidentiality Statement to Users of the Information Technology Web Services (ITWS).)
Vendor Access for the Following Counties/Direct Providers:
(Please indicate the six digit provider ID for each provider the vendor is requesting access to in order to upload and submit CalOMS Tx data)
NOTE: This form is not valid unless the County/Direct Provider has approved vendor access to their
data. Form DHCS 5099 should accompany this form.
Vendor Executive Officer Approver:
I hereby certify that this organization is a vendor for the above-named counties/direct providers and designate the individuals
identified above to have independent authority to approve ITWS access requests to specific confidential county/direct provider
CalOMS Treatment patient data. DHCS may rely on approvals, denials, and changes made by these individuals in its processing of
access requests for the above listed counties’/direct providers’ data. As changes occur to the above approving contacts (name, phone,
e-mail or county/direct provider), I will complete a new certification and fax it to DHCS. Also, I acknowledge reading the attached
Confidentiality Statement to Users of the Information Technology Web Services (ITWS).
By:
Date:
(signed and printed)
Title:
DHCS 5100 (06/13)
ADP 100178 (06/13)
State of California — Health and Human Services Agency
Department of Health Care Services
CalOMS
MS 2603
PO Box 997413
Sacramento, CA 95899-7413
CalOMS Tx ITWS Vendor Approver Form
DHCS Approved
Date
Approver
For Granting Access to the CalOMS Treatment Data System
Vendor (System) Name:
To ensure the confidentiality of county/direct provider CalOMS Treatment data, the Department of Health Care Services (DHCS)
requires that each designated vendor identify a primary and a secondary contact to be responsible for approving requests for ITWS
access to confidential county/direct provider confidential patient data in the CalOMS Treatment data system. Please complete and fax
this form to DHCS at (916) 322-7117. If you have questions about this form, please call (916) 327-3010 or e-mail
CalOMSHelp@DHCS.ca.gov.
Please print all information
Primary Vendor (User):
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: (
)
Email Address:
Primary Approver’s Signature:
(Signer acknowledges having read the Confidentiality Statement to Users of the Information Technology Web Services (ITWS).)
Secondary Vendor (User):
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: (
)
Email Address:
Secondary Approver’s Signature:
(Signer acknowledges having read the Confidentiality Statement to Users of the Information Technology Web Services (ITWS).)
Vendor Access for the Following Counties/Direct Providers:
(Please indicate the six digit provider ID for each provider the vendor is requesting access to in order to upload and submit CalOMS Tx data)
NOTE: This form is not valid unless the County/Direct Provider has approved vendor access to their
data. Form DHCS 5099 should accompany this form.
Vendor Executive Officer Approver:
I hereby certify that this organization is a vendor for the above-named counties/direct providers and designate the individuals
identified above to have independent authority to approve ITWS access requests to specific confidential county/direct provider
CalOMS Treatment patient data. DHCS may rely on approvals, denials, and changes made by these individuals in its processing of
access requests for the above listed counties’/direct providers’ data. As changes occur to the above approving contacts (name, phone,
e-mail or county/direct provider), I will complete a new certification and fax it to DHCS. Also, I acknowledge reading the attached
Confidentiality Statement to Users of the Information Technology Web Services (ITWS).
By:
Date:
(signed and printed)
Title:
DHCS 5100 (06/13)
ADP 100178 (06/13)