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- Instructions for Form DHCS8049 "County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan" - California
Instructions for Form DHCS8049 "County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan" - California
This document contains official instructions for Form DHCS8049, County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan - a form released and collected by the California Department of Health Care Services. An up-to-date fillable Form DHCS8049 is available for download through this link.
Instruction Details:
- This 1-page document is available for download in PDF;
- Actual and applicable for the current year;
- Complete, printable, and free.
Download your copy of the instructions by clicking the link below or browse hundreds of other forms in our library of forms released by the California Department of Health Care Services.
Download Instructions for Form DHCS8049 "County Certification of Compliance With Drug Medi-Cal Post Service Post Payment Corrective Action Plan" - California
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1STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR COUNTY CERTIFICATION OF COMPLIANCE WITH DRUG MEDI-CAL POST SERVICE POST
PAYMENT CORRECTIVE ACTION PLAN DHCS 8049
GENERAL
The County Certification of Compliance with Drug Medi-Cal Post Service Post Payment Corrective Action Plan Form is used to certify a providers’
full implementation of a Corrective Action Plan (CAP) generated as a result of a DHCS Post Service Post Payment review. The form must be
completed and submitted to DHCS by the County Substance Use Disorder Program Administrator or County designated authority after on-site
verification of CAP implementation.
HEADING INSTRUCTIONS
PROVIDER NAME: enter the name of provider for which the Corrective Action Plan was submitted.
DMC #: enter Drug Medi-Cal provider number assigned by DHCS.
DATE OF PROVIDER CAP: enter the date the approved CAP was submitted.
SIGNATURE BLOCK INSTRUCTIONS
PRINT NAME: print the name of individual authorized to submit form.
TITLE: print title of individual authorized to submit form.
SIGNATURE: authorized submitter must sign.
DATE: enter date form is submitted to DHCS.
PHONE: enter phone number of authorized submitter.
E-MAIL: enter e-mail address of authorized submitter.
AGENCY: enter name of Agency submitting form.
COUNTY: enter name of county from which form is submitted.
DHCS 8049 INS (4/15)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
COMPLETION INSTRUCTIONS FOR COUNTY CERTIFICATION OF COMPLIANCE WITH DRUG MEDI-CAL POST SERVICE POST
PAYMENT CORRECTIVE ACTION PLAN DHCS 8049
GENERAL
The County Certification of Compliance with Drug Medi-Cal Post Service Post Payment Corrective Action Plan Form is used to certify a providers’
full implementation of a Corrective Action Plan (CAP) generated as a result of a DHCS Post Service Post Payment review. The form must be
completed and submitted to DHCS by the County Substance Use Disorder Program Administrator or County designated authority after on-site
verification of CAP implementation.
HEADING INSTRUCTIONS
PROVIDER NAME: enter the name of provider for which the Corrective Action Plan was submitted.
DMC #: enter Drug Medi-Cal provider number assigned by DHCS.
DATE OF PROVIDER CAP: enter the date the approved CAP was submitted.
SIGNATURE BLOCK INSTRUCTIONS
PRINT NAME: print the name of individual authorized to submit form.
TITLE: print title of individual authorized to submit form.
SIGNATURE: authorized submitter must sign.
DATE: enter date form is submitted to DHCS.
PHONE: enter phone number of authorized submitter.
E-MAIL: enter e-mail address of authorized submitter.
AGENCY: enter name of Agency submitting form.
COUNTY: enter name of county from which form is submitted.
DHCS 8049 INS (4/15)
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