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- "County-Based Medi-Cal Administrative Activities (Cmaa) Time Survey Request Form" - California
"County-Based Medi-Cal Administrative Activities (Cmaa) Time Survey Request Form" - California
County-Based Medi-Cal Administrative Activities (Cmaa) Time Survey Request Form is a legal document that was released by the California Department of Health Care Services - a government authority operating within California.
Form Details:
- Released on January 1, 2008;
- The latest edition currently provided by the California Department of Health Care Services;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of the form by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.
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2CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
COUNTY-BASED MEDI-CAL ADMINISTRATIVE ACTIVITIES
(CMAA)
TIME SURVEY REQUEST FORM
SUBMIT ONE FORM PER CLAIMING UNIT AT LEAST 30 DAYS PRIOR TO
THE REQUESTED TIME SURVEY MONTH.
_____________________________________________
Local Governmental Agency (LGA)
Mail to:
_____________________________________________
Department of Health Care Services
Safety Net Financing Division
Claiming Unit Name (as it appears in the Claiming Plan)
Administrative Claiming Local & Schools
Services Branch
County-Based Medi-Cal Administrative
Activities Unit
_____________________________________________
Attn: (Program Analyst Name)
Address
1501 Capitol Avenue, Suite 71.2101
P.O. Box 997436, MS 4603
Sacramento, CA 95899-7436
_____________________________________________
City
State
Zip
The LGA identified above, requests approval from the Department of Health Care Services
(DHCS) to conduct a time survey for County-Based Medi-Cal Administrative Activities as follows:
Fiscal Year ___________________ during the month of _____________________ _____.
MONTH
YEAR
We understand that the process of this time survey must meet the same criteria as the time
survey period designated by the DHCS. Results from this time survey shall be in effect from the
first day of the calendar quarter in which the time survey is conducted, and shall remain in effect
until superseded by an additional approved subsequent time survey or by the mandatory time
survey in the next fiscal year.
_________________________________
(_____)___________________
Contact Person (print)
Telephone Number
_________________________________
__________________________
Signature
Date
DHCS USE ONLY
Approved by DHCS
____________________
Denied by DHCS
____________________
________________________________ __________
Signature
Date
Revised 1-08
CALIFORNIA DEPARTMENT OF HEALTH CARE SERVICES
COUNTY-BASED MEDI-CAL ADMINISTRATIVE ACTIVITIES
(CMAA)
TIME SURVEY REQUEST FORM
SUBMIT ONE FORM PER CLAIMING UNIT AT LEAST 30 DAYS PRIOR TO
THE REQUESTED TIME SURVEY MONTH.
_____________________________________________
Local Governmental Agency (LGA)
Mail to:
_____________________________________________
Department of Health Care Services
Safety Net Financing Division
Claiming Unit Name (as it appears in the Claiming Plan)
Administrative Claiming Local & Schools
Services Branch
County-Based Medi-Cal Administrative
Activities Unit
_____________________________________________
Attn: (Program Analyst Name)
Address
1501 Capitol Avenue, Suite 71.2101
P.O. Box 997436, MS 4603
Sacramento, CA 95899-7436
_____________________________________________
City
State
Zip
The LGA identified above, requests approval from the Department of Health Care Services
(DHCS) to conduct a time survey for County-Based Medi-Cal Administrative Activities as follows:
Fiscal Year ___________________ during the month of _____________________ _____.
MONTH
YEAR
We understand that the process of this time survey must meet the same criteria as the time
survey period designated by the DHCS. Results from this time survey shall be in effect from the
first day of the calendar quarter in which the time survey is conducted, and shall remain in effect
until superseded by an additional approved subsequent time survey or by the mandatory time
survey in the next fiscal year.
_________________________________
(_____)___________________
Contact Person (print)
Telephone Number
_________________________________
__________________________
Signature
Date
DHCS USE ONLY
Approved by DHCS
____________________
Denied by DHCS
____________________
________________________________ __________
Signature
Date
Revised 1-08
Revised 1-08
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