Form DHCS5261 "County Approver Certification and Vendor Appointment Form for Access to California Outcomes Measurement System (Caloms Tx)" - California

What Is Form DHCS5261?

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 May 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 DHCS5261 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 DHCS5261 "County Approver Certification and Vendor Appointment Form for Access to California Outcomes Measurement System (Caloms Tx)" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
County Approver Certification & Vendor Appointment Form
For Access to California Outcomes Measurement System (CalOMS Tx)
County Name:
To ensure the confidentiality of county SUD data, the Department of Health Care Services, requests the
county behavioral health director designate two contacts to be responsible for approving county (and vendor,
if applicable) staff requests for access to the CalOMS Tx system.
CalOMSRewrite@dhcs.ca.gov.
The
Please complete the information below and email the signed form to
email must be sent from the signer’s email account. If you have any questions, please email to
CalOMSRewrite@dhcs.ca.gov.
Approver I:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Approver II:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Appointed Vendor(s): (If applicable)
The vendor listed below has the authority to receive, send and process the above named
county’s confidential Drug Medi-Cal information in the CalOMS Tx system. (The designated
county approvers will approve vendor access requests)
Vendor Name:
Phone Number:
Vendor Contact Name:
Contact Email Address:
County AOD Administrator/Executive Officer Certification:
I, the undersigned (check all that apply):
□ Designate the above county individuals to have independent authority to approve access requests to
the CalOMS Tx system. DHCS may rely on approvals, denials, and changes made by the above
individuals in its processing of access requests to this county’s data in the CalOMS Tx systems. As
changes occur to the above approving contacts or vendor information, I will sign an updated certification
and forward it to DHCS.
□ Appoint the above vendor to have authority to receive, send and process the above named county’s
confidential Drug Medi-Cal information in the CalOMS Tx system.
County AOD Administrator/Executive Officer (Signature)
Date
County AOD Administrator/Executive Officer
County AOD Administrator/Executive Officer (Print Name)
(E-mail address)
DHCS 5261 (Rev. 05/01/2018
State of California
Department of Health Care Services
Health and Human Services Agency
County Approver Certification & Vendor Appointment Form
For Access to California Outcomes Measurement System (CalOMS Tx)
County Name:
To ensure the confidentiality of county SUD data, the Department of Health Care Services, requests the
county behavioral health director designate two contacts to be responsible for approving county (and vendor,
if applicable) staff requests for access to the CalOMS Tx system.
CalOMSRewrite@dhcs.ca.gov.
The
Please complete the information below and email the signed form to
email must be sent from the signer’s email account. If you have any questions, please email to
CalOMSRewrite@dhcs.ca.gov.
Approver I:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Approver II:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Appointed Vendor(s): (If applicable)
The vendor listed below has the authority to receive, send and process the above named
county’s confidential Drug Medi-Cal information in the CalOMS Tx system. (The designated
county approvers will approve vendor access requests)
Vendor Name:
Phone Number:
Vendor Contact Name:
Contact Email Address:
County AOD Administrator/Executive Officer Certification:
I, the undersigned (check all that apply):
□ Designate the above county individuals to have independent authority to approve access requests to
the CalOMS Tx system. DHCS may rely on approvals, denials, and changes made by the above
individuals in its processing of access requests to this county’s data in the CalOMS Tx systems. As
changes occur to the above approving contacts or vendor information, I will sign an updated certification
and forward it to DHCS.
□ Appoint the above vendor to have authority to receive, send and process the above named county’s
confidential Drug Medi-Cal information in the CalOMS Tx system.
County AOD Administrator/Executive Officer (Signature)
Date
County AOD Administrator/Executive Officer
County AOD Administrator/Executive Officer (Print Name)
(E-mail address)
DHCS 5261 (Rev. 05/01/2018