Form MC5123AD "Dhcs Employee Approver Certification" - California

What Is Form MC5123AD?

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 June 1, 2012;
  • 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 MC5123AD 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 MC5123AD "Dhcs Employee Approver Certification" - California

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State of California - Health and Human Services
Department of Health Care Services
DHCS Employee Approver Certification
DHCS Approved
(DHCS use only)
Date
Approver
For Access to Confidential DHCS Drug Medi-Cal
DHCS Branch
:
To ensure the confidentiality of Drug Medi-Cal (DMC) data, the Department of Health Care Services (DHCS) requests
the appropriate DHCS Manager designate a primary and a secondary contact to be responsible for approving
employee requests for access to confidential patient data in the Short-Doyle/Medi-Cal claims system. Please provide this
information in the spaces below and fax this form to (916) 323-0653. If you have any questions about this form,
please call (916) 323-2043.
Primary Approver:
First Name:
Last Name:
Title:
Phone Number:
Fax Number
:
Email Address:
Primary Approver’s Signature:
__________________________________________________
(Signer acknowledges having read the Confidentiality Statement for all DHCS AOD/ITWS users)
Secondary Approver:
First Name:
Last Name:
Title:
Phone Number:
Fax Number
:
Email Address:
Secondary Approver’s Signature:
(Signer acknowledges having read the Confidentiality Statement for all DHCS AOD/ITWS users)
DHCS Certification:
As Manager of
, I designate the above individuals to have
(unit name)
independent authority to approve access requests to specific confidential Drug Medi-Cal data. The DHCS may rely on
approvals, denials, and changes made by these individuals in its processing of access requests to the Short-Doyle/Medi-Cal
claims system. As changes occur to the above approving contact’s information (name, phone, e-mail or system), I will sign
an updated certification and forward it to DHCS ITWS. Also, I acknowledge reading the Confidentiality Statement for all
DHCS AOD users of the ITWS.
_________________________________________________________________
_________________
Manager
(signed and printed)
Date
MC 5123AD (6/12)
State of California - Health and Human Services
Department of Health Care Services
DHCS Employee Approver Certification
DHCS Approved
(DHCS use only)
Date
Approver
For Access to Confidential DHCS Drug Medi-Cal
DHCS Branch
:
To ensure the confidentiality of Drug Medi-Cal (DMC) data, the Department of Health Care Services (DHCS) requests
the appropriate DHCS Manager designate a primary and a secondary contact to be responsible for approving
employee requests for access to confidential patient data in the Short-Doyle/Medi-Cal claims system. Please provide this
information in the spaces below and fax this form to (916) 323-0653. If you have any questions about this form,
please call (916) 323-2043.
Primary Approver:
First Name:
Last Name:
Title:
Phone Number:
Fax Number
:
Email Address:
Primary Approver’s Signature:
__________________________________________________
(Signer acknowledges having read the Confidentiality Statement for all DHCS AOD/ITWS users)
Secondary Approver:
First Name:
Last Name:
Title:
Phone Number:
Fax Number
:
Email Address:
Secondary Approver’s Signature:
(Signer acknowledges having read the Confidentiality Statement for all DHCS AOD/ITWS users)
DHCS Certification:
As Manager of
, I designate the above individuals to have
(unit name)
independent authority to approve access requests to specific confidential Drug Medi-Cal data. The DHCS may rely on
approvals, denials, and changes made by these individuals in its processing of access requests to the Short-Doyle/Medi-Cal
claims system. As changes occur to the above approving contact’s information (name, phone, e-mail or system), I will sign
an updated certification and forward it to DHCS ITWS. Also, I acknowledge reading the Confidentiality Statement for all
DHCS AOD users of the ITWS.
_________________________________________________________________
_________________
Manager
(signed and printed)
Date
MC 5123AD (6/12)