Form DHCS4507 "Special Care Center (Scc) Directory Update" - California

What Is Form DHCS4507?

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 January 1, 2008;
  • 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 DHCS4507 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 DHCS4507 "Special Care Center (Scc) Directory Update" - California

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State of California – Health and Human Services Agency
Department of Health Care Services
SPECIAL CARE CENTER (SCC) DIRECTORY UPDATE
To:
Provider and Facility Site Review Unit
Contact person: ______________________________
Facility name: ________________________________
E-mail: CCSFacilityData@dhcs.ca.gov
SCC #: ______________________________________
Phone: ______________________________________
Date:
___________________________________
Total pages: __________________________________
__________________________________________
_____________________________________________
Medical Director (Print)
Medical Director (Signature)
INSTRUCTIONS
1.
Find and print your SCC directory listing in the Special Care Center section of the CCS website
www.dhcs.ca.gov.services/ccs.
2.
Fill in the changes (including additions or removals of staff) directly on your SCC directory listing. Please ensure you
provide the NPI number, as there are many similar names.
3.
If staff have been added to or removed from your SCC directory listing, supply their active Provide Number,
discipline, and effective date(s) using the table below.
DISCIPLINE
STAFF NPI
STAFF NAME
EFFECTIVE DATE
(i.e. Pediatric
and/or LICENSE
ACTION
(Last Name, First Name)
(MM/DD/YY)
Cardiology)
NUMBER
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
4.
Complete the top portion of this cover sheet. The Medical Director must sign this cover sheet.
5.
E-mail the completed cover sheet and your edited SCC directory listing to
CCSFacilityData@dhcs.ca.gov
6.
Updates are made routinely. Changes are posted on the CCS website at the end of each workweek.
DHCS4507 (01/08)
State of California – Health and Human Services Agency
Department of Health Care Services
SPECIAL CARE CENTER (SCC) DIRECTORY UPDATE
To:
Provider and Facility Site Review Unit
Contact person: ______________________________
Facility name: ________________________________
E-mail: CCSFacilityData@dhcs.ca.gov
SCC #: ______________________________________
Phone: ______________________________________
Date:
___________________________________
Total pages: __________________________________
__________________________________________
_____________________________________________
Medical Director (Print)
Medical Director (Signature)
INSTRUCTIONS
1.
Find and print your SCC directory listing in the Special Care Center section of the CCS website
www.dhcs.ca.gov.services/ccs.
2.
Fill in the changes (including additions or removals of staff) directly on your SCC directory listing. Please ensure you
provide the NPI number, as there are many similar names.
3.
If staff have been added to or removed from your SCC directory listing, supply their active Provide Number,
discipline, and effective date(s) using the table below.
DISCIPLINE
STAFF NPI
STAFF NAME
EFFECTIVE DATE
(i.e. Pediatric
and/or LICENSE
ACTION
(Last Name, First Name)
(MM/DD/YY)
Cardiology)
NUMBER
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
Add
Remove
4.
Complete the top portion of this cover sheet. The Medical Director must sign this cover sheet.
5.
E-mail the completed cover sheet and your edited SCC directory listing to
CCSFacilityData@dhcs.ca.gov
6.
Updates are made routinely. Changes are posted on the CCS website at the end of each workweek.
DHCS4507 (01/08)