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.

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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)
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)