Form DHCS5262 "Dcr County Approver Certification and Vendor Appointment Form" - California

What Is Form DHCS5262?

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 July 1, 2017;
  • 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 fillable version of Form DHCS5262 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 DHCS5262 "Dcr County Approver Certification and Vendor Appointment Form" - California

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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 Data Collection and Reporting (DCR) 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 DCR
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 DCR 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
DCR system. DHCS may rely on approvals, denials, and changes made by the above individuals inits
processing of access requests to this county’s data in the DCR 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 DCR system.
County Behavioral Health Director (Signature)
Date
County Behavioral Health Director (Print Name)
County Behavioral Health Director (E-mail address)
DHCS 5262 (Rev. 07/17)
State of California
Department of Health Care Services
Health and Human Services Agency
County Approver Certification & Vendor Appointment Form
For Access to Mental Health Data Collection and Reporting (DCR) 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 DCR
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 DCR 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
DCR system. DHCS may rely on approvals, denials, and changes made by the above individuals inits
processing of access requests to this county’s data in the DCR 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 DCR system.
County Behavioral Health Director (Signature)
Date
County Behavioral Health Director (Print Name)
County Behavioral Health Director (E-mail address)
DHCS 5262 (Rev. 07/17)