Form DHCS 8049 County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan - California

Form DHCS8049 or the "County Certification Of Compliance With Drug Medi-cal Post Service Post Payment Corrective Action Plan" is a form issued by the California Department of Health Care Services.

The form was last revised in April 1, 2015 and is available for digital filing. Download an up-to-date fillable Form DHCS8049 in PDF-format down below or look it up on the California Department of Health Care Services Forms website.

Step-by-step Form 8049 instructions can be downloaded by clicking this link.

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Department of Health Care Services
Substance Use Disorders Services
COUNTY CERTIFICATION OF COMPLIANCE
WITH DRUG MEDI-CAL
POST SERVICE POST PAYMENT
CORRECTIVE ACTION PLAN
I hereby certify that __________________________________, DMC #_________, has
(Provider Name)
fully implemented all corrective actions documented and submitted to the Department of
Health Care Services on ______________________.
(Date of Provider CAP)
__________________________________________           _______________________________________    
Print Name
Title
__________________________________
________________________________
Signature
Date
_____________________________________
___________________________________  
Phone
E-mail
__________________________________
________________________________
Agency
County
Regulation:
State County Contract SFY 14/15
Exhibit A, Attachment I, Part V, Section 4, B (1)(d):
Contractor must monitor and certify compliance and/or completion by Providers with CAP
requirements (detailed in Section 4, Paragraph (A)(2)(c))as required by any PSPP review.
Contractor shall certify to DHCS, using the form developed by DHCS that the requirements in the
CAP have been completed by the Contractor and/or the Provider. Submission of form by
Contractor must be accomplished within the timeline specified in the approved CAP, as noticed
by DHCS.
Please submit form to:
SudCountyReports@dhcs.ca.gov
DHCS 8049 (4/15)
 
 
 
 
 
 
 
 
 
 
              
 
 
 
 
 
 
 
 
 
 
 
 
 
Department of Health Care Services
Substance Use Disorders Services
COUNTY CERTIFICATION OF COMPLIANCE
WITH DRUG MEDI-CAL
POST SERVICE POST PAYMENT
CORRECTIVE ACTION PLAN
I hereby certify that __________________________________, DMC #_________, has
(Provider Name)
fully implemented all corrective actions documented and submitted to the Department of
Health Care Services on ______________________.
(Date of Provider CAP)
__________________________________________           _______________________________________    
Print Name
Title
__________________________________
________________________________
Signature
Date
_____________________________________
___________________________________  
Phone
E-mail
__________________________________
________________________________
Agency
County
Regulation:
State County Contract SFY 14/15
Exhibit A, Attachment I, Part V, Section 4, B (1)(d):
Contractor must monitor and certify compliance and/or completion by Providers with CAP
requirements (detailed in Section 4, Paragraph (A)(2)(c))as required by any PSPP review.
Contractor shall certify to DHCS, using the form developed by DHCS that the requirements in the
CAP have been completed by the Contractor and/or the Provider. Submission of form by
Contractor must be accomplished within the timeline specified in the approved CAP, as noticed
by DHCS.
Please submit form to:
SudCountyReports@dhcs.ca.gov
DHCS 8049 (4/15)

Download Form DHCS 8049 County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan - California

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