Form DHCS4074 "Microsoft Business Intelligence Account Request" - California

What Is Form DHCS4074?

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 August 1, 2018;
  • 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 DHCS4074 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 DHCS4074 "Microsoft Business Intelligence Account Request" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
Integrated Systems of Care Division (ISCD)
Submit Form: Fax: (916) 440-5346 or
MICROSOFT BUSINESS INTELLIGENCE
Scan and email:
cmshelp@dhcs.ca.gov
ACCOUNT REQUEST
Questions?
Contact the CMS Net Help Desk
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This form is to be used by California Children’s Services (CCS), Child Health & Disability Prevention (CHDP), and Genetically
Handicapped Persons Program (GHPP) to request access to data through Microsoft Business Intelligence for State and local
program staff. Fill in the appropriate checkboxes and complete the requested information for all requests. Please type or print
legibly and allow time for processing requests.
County/Local Program/Office:
Select
Phone
Access
Name (Last, First) and Email
One
(999)999-9999
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Address:
Representative’s Name (Print):
Phone:
Representative’s Name (Signature):
Date:
DHCS 4074 (Rev 08/18)
Page 1 of 3
State of California—Health and Human Services Agency
Department of Health Care Services
Integrated Systems of Care Division (ISCD)
Submit Form: Fax: (916) 440-5346 or
MICROSOFT BUSINESS INTELLIGENCE
Scan and email:
cmshelp@dhcs.ca.gov
ACCOUNT REQUEST
Questions?
Contact the CMS Net Help Desk
(866) 685-8449 or
cmshelp@dhcs.ca.gov
This form is to be used by California Children’s Services (CCS), Child Health & Disability Prevention (CHDP), and Genetically
Handicapped Persons Program (GHPP) to request access to data through Microsoft Business Intelligence for State and local
program staff. Fill in the appropriate checkboxes and complete the requested information for all requests. Please type or print
legibly and allow time for processing requests.
County/Local Program/Office:
Select
Phone
Access
Name (Last, First) and Email
One
(999)999-9999
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Add
CCS
Modify
CHDP Gateway
Delete
GHPP
Address:
Representative’s Name (Print):
Phone:
Representative’s Name (Signature):
Date:
DHCS 4074 (Rev 08/18)
Page 1 of 3
State of California—Health and Human Services Agency
Department of Health Care Services
Integrated Systems of Care Division (ISCD)
DEPARTMENT OF HEALTH CARE SERVICES COMPUTER FILES
RELEASE/ACCESS FOR THE MEDI-CAL, CCS, CHDP,
AND CHDP GATEWAY, and GHPP PROGRAMS
CONFIDENTIALITY OATH
As a condition of obtaining access to data and fiscal/reporting records utilized/maintained by the State Department of Health
Care Services and its fiscal intermediary, I agree not to:
1. Divulge any information obtained in the course of my assigned duties to unauthorized persons,
2. Publish or otherwise make public any information regarding persons(s) receiving Medi-Cal, CCS, CHDP, or GHPP services
such that the persons who received such services are identifiable.
Access to such data shall be limited to state and federal personnel who require the information in the performance of their duties
and to others such as local health department CCS/CHDP program staff as may be authorized by the Department of Health Care
Services.
I recognize that unauthorized release of confidential information may be subject to civil and criminal sanctions pursuant to the
provisions of the Welfare and Institutions Code Section 14100.2.
County/Local Program/Office:
Printed Name of Staff
Staff Signature
Date
DHCS 4074 (Rev 08/18)
Page 2 of 3
State of California—Health and Human Services Agency
Department of Health Care Services
Integrated Systems of Care Division (ISCD)
INSTRUCTIONS
County/Local Program:
The name of the county or local program submitting request.
Select One:
Add:
Select check box if this request is for account activation.
Modify:
Select check box if this request is for account modification.
Delete:
Select check box if this request is for account deactivation.
Access:
CCS:
Select check box for access to create/view/modify CCS reports.
CHDP:
Select check box for access to create/view/modify CHDP reports.
GHPP:
Select check box for access to create/view/modify GHPP reports.
Name (Last, First) and Email:
Type user’s last name, then user’s first name and user’s email address.
Phone:
Type user’s phone number, including area code (and extension if applicable) in format
(999)999-9999.
Address:
Type the work address of the users listed above. Include number, street, suite number,
city or town, state, and ZIP code. If more than one location, list the primary work address
of the office or use a different form for each address.
Representative’s Name (Print):
Type the name of the person submitting request. Representative must be a State ISCD
Branch manager, CCS/CMS Administrator, CHDP Director, or CHDP Deputy Director.
Phone:
Type the representative’s phone number, including area code (and extension if
applicable) in format (999)999-9999.
Representative’s Name (Signature): Signature of representative.
Date:
Date account request was signed by the representative.
County/Local Program:
The name of the county or local program submitting request.
Printed Name of Staff:
Name of user(s) with the “Add” option selected. Each user with the “Add” option selected
must be listed.
Staff Signature:
Signature of user(s) with the “Add” option selected. Each user with the “Add” option
selected must sign the confidentiality oath.
Date:
Date user(s) with “Add” option selected signed the form.
DHCS 4074 (Rev 08/18)
Page 3 of 3
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