Form MC5131AD "County/Direct Provider User Cancellation" - California

What Is Form MC5131AD?

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 MC5131AD 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 MC5131AD "County/Direct Provider User Cancellation" - California

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State of California - Health and Human Services Agency
Department of Health Care Services
County/Direct Provider User Cancellation
DHCS Approved
(DHCS Use Only)
Date
Approver
For Canceling User Access to Confidential DHCS Drug Medi-Cal
County/Direct Provider/Vendor:
To ensure the confidentiality of county/direct provider Drug Medi-Cal (DMC) data, the Department of Health Care Services
(DHCS) requests the County DHCS AOD Administrator, Direct Provider Executive Officer or Vendor Executive Officer to
notify DHCS when previously approved users should no longer be allowed access to confidential patient data in the system listed
below. Please complete the information below and fax this form to (916) 323-0653. If you have questions about this form,
please call (916) 323-2043.
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
DHCS AOD Administrator/Executive Officer Certification:
As AOD Administrator/Executive Officer for
(County/Direct Provider/Vendor),
I designate the above individual(s) no longer has/have access requests to specific confidential Drug Medi-Cal patient data.
DHCS AOD Administrator/Executive Officer
(signed and printed)
Date
MC 5131AD (6/12)
State of California - Health and Human Services Agency
Department of Health Care Services
County/Direct Provider User Cancellation
DHCS Approved
(DHCS Use Only)
Date
Approver
For Canceling User Access to Confidential DHCS Drug Medi-Cal
County/Direct Provider/Vendor:
To ensure the confidentiality of county/direct provider Drug Medi-Cal (DMC) data, the Department of Health Care Services
(DHCS) requests the County DHCS AOD Administrator, Direct Provider Executive Officer or Vendor Executive Officer to
notify DHCS when previously approved users should no longer be allowed access to confidential patient data in the system listed
below. Please complete the information below and fax this form to (916) 323-0653. If you have questions about this form,
please call (916) 323-2043.
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
User No Longer Authorized Access as of
(Date)
First Name:
Last Name:
Username:
Phone Number:
Fax Number:
Email Address:
DHCS AOD Administrator/Executive Officer Certification:
As AOD Administrator/Executive Officer for
(County/Direct Provider/Vendor),
I designate the above individual(s) no longer has/have access requests to specific confidential Drug Medi-Cal patient data.
DHCS AOD Administrator/Executive Officer
(signed and printed)
Date
MC 5131AD (6/12)