Form DHCS8049 "County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan" - California

What Is Form DHCS8049?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on April 1, 2015;
  • 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;

Download a fillable version of Form DHCS8049 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 DHCS8049 "County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan" - California

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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)