Form Dhcs5260 "Fast County Approver Certification & Vendor Appointment Form" - California

Form DHCS5260 is a California Department of Health Care Services form also known as the "Fast County Approver Certification & Vendor Appointment Form". The latest edition of the form was released in June 1, 2018 and is available for digital filing.

Download a fillable PDF version of the Form DHCS5260 down below or find it on California Department of Health Care Services Forms website.

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State of California
Department of Health Care Services
Health and Human Services Agency
County Approver Certification & Vendor Appointment Form
For Access to Mental Health Functional Assessment Screening Tool (FAST) System
County Name:
To ensure the confidentiality of county mental health data, the Department of Health Care Services,
requests the county behavioral health director designate two contacts to be responsible for approving
county (and vendor, if applicable) staff requests for access to the confidential patient data in the FAST
system.
Please complete the information below and email the signed form to MHSData@dhcs.ca.gov. The email
must be sent from the signer’s (Behavioral Health Director’s) email account. If you have any questions,
please email to
MHSData@dhcs.ca.gov.
Approver I:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Approver II:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Appointed Vendor(s): (If applicable)
The vendor listed below has the authority to receive, send and process the above named
county’s confidential mental health information in the FAST system. (The designated
county approvers will approve vendor access requests)
Vendor Name:
Vendor Contact Name:
Contact Email Address:
County Behavioral Health Director Certification:
I, the undersigned (check all that apply):
□ Designate the above county individuals to have independent authority to approve access requests to the
FAST system. DHCS may rely on approvals, denials, and changes made by the above individuals in its
processing of access requests to this county’s data in the FAST system. As changes occur to the above
approving contacts or vendor information, I will sign an updated certification and forward it to DHCS.
□ Appoint the above vendor to have authority to receive, send and process the above named county’s
confidential mental health information in the FAST system.
County Behavioral Health Director (Signature)
Date
County Behavioral Health Director (Print Name)
County Behavioral Health Director (E-mail address)
DHCS 5260 (Rev. 06/18)
State of California
Department of Health Care Services
Health and Human Services Agency
County Approver Certification & Vendor Appointment Form
For Access to Mental Health Functional Assessment Screening Tool (FAST) System
County Name:
To ensure the confidentiality of county mental health data, the Department of Health Care Services,
requests the county behavioral health director designate two contacts to be responsible for approving
county (and vendor, if applicable) staff requests for access to the confidential patient data in the FAST
system.
Please complete the information below and email the signed form to MHSData@dhcs.ca.gov. The email
must be sent from the signer’s (Behavioral Health Director’s) email account. If you have any questions,
please email to
MHSData@dhcs.ca.gov.
Approver I:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Approver II:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Appointed Vendor(s): (If applicable)
The vendor listed below has the authority to receive, send and process the above named
county’s confidential mental health information in the FAST system. (The designated
county approvers will approve vendor access requests)
Vendor Name:
Vendor Contact Name:
Contact Email Address:
County Behavioral Health Director Certification:
I, the undersigned (check all that apply):
□ Designate the above county individuals to have independent authority to approve access requests to the
FAST system. DHCS may rely on approvals, denials, and changes made by the above individuals in its
processing of access requests to this county’s data in the FAST system. As changes occur to the above
approving contacts or vendor information, I will sign an updated certification and forward it to DHCS.
□ Appoint the above vendor to have authority to receive, send and process the above named county’s
confidential mental health information in the FAST system.
County Behavioral Health Director (Signature)
Date
County Behavioral Health Director (Print Name)
County Behavioral Health Director (E-mail address)
DHCS 5260 (Rev. 06/18)
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