Form MC5257 "Dhcs Branch Approver Certification for Access to Confidential Mental Health Information" - California

What Is Form MC5257?

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 March 1, 2013;
  • 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 MC5257 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 MC5257 "Dhcs Branch Approver Certification for Access to Confidential Mental Health Information" - California

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State of California - Health and Human Services Agency
Department of Health Care Services
DHCS Branch Approver Certification
MC 5257 (03/13)
For Access to Confidential Mental Health Information
DHCS Branch:
To ensure the confidentiality of mental health data, the Department of Health Care Services, Information Technology Web
Services (DHCS-ITWS) requests the appropriate DHCS chief designate a primary and a secondary contact to be responsible for
approving DHCS employee requests for access to confidential patient data in the systems checked below. Please provide this
information in the spaces below and e - m a i l c o m p l e t e d form to "D H C S M H S D A P P C e r t @ d h c s . c a . g o v " . If you
have any questions, please contact MHSD-App-Cert group via above mentioned e-mail.
Primary Approver:
First Name:
Last Name:
Title:
Fax Number:
Phone Number:
Email Address:
Primary Approver’s Signature:
(I have read
Letter No. 99-02
regarding Confidentiality of Client Information)
Secondary Approver:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Secondary Approver’s Signature:
(I have read
Letter No. 99-02
regarding Confidentiality of Client Information)
Mental Health Systems:
Please check the systems for which the above approvers may authorize access requests:
CFRS
POQI
Cost and Financial Reporting System
Performance Outcome Quality Improvement
MHSA
Mental Health Services Act
(aka Consumer Perception Survey)
MMEF
PRV/LE
Monthly MEDS Extract File
Provider/Legal Entity
SD/MC
Short-Doyle/Medi-Cal Claims
SDA
Statistics and Data Analysis
(aka Mental Health Analytics)
DHCS Branch Approver Certification:
I designate the above individuals to have independent authority to approve access requests to specific confidential mental
health patient data. DHCS-ITWS may rely on approvals, denials, and changes made by these individuals in its processing of
access requests to the above selected system(s). 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 "DHCSMHSDAPPCert@dhcs.ca.gov". Also,
I acknowledge reading
Letter No. 99-02
regarding Confidentiality of Client Information.
DHCS Branch Chief (Signature)
Printed
Date
State of California - Health and Human Services Agency
Department of Health Care Services
DHCS Branch Approver Certification
MC 5257 (03/13)
For Access to Confidential Mental Health Information
DHCS Branch:
To ensure the confidentiality of mental health data, the Department of Health Care Services, Information Technology Web
Services (DHCS-ITWS) requests the appropriate DHCS chief designate a primary and a secondary contact to be responsible for
approving DHCS employee requests for access to confidential patient data in the systems checked below. Please provide this
information in the spaces below and e - m a i l c o m p l e t e d form to "D H C S M H S D A P P C e r t @ d h c s . c a . g o v " . If you
have any questions, please contact MHSD-App-Cert group via above mentioned e-mail.
Primary Approver:
First Name:
Last Name:
Title:
Fax Number:
Phone Number:
Email Address:
Primary Approver’s Signature:
(I have read
Letter No. 99-02
regarding Confidentiality of Client Information)
Secondary Approver:
First Name:
Last Name:
Title:
Phone Number:
Fax Number:
Email Address:
Secondary Approver’s Signature:
(I have read
Letter No. 99-02
regarding Confidentiality of Client Information)
Mental Health Systems:
Please check the systems for which the above approvers may authorize access requests:
CFRS
POQI
Cost and Financial Reporting System
Performance Outcome Quality Improvement
MHSA
Mental Health Services Act
(aka Consumer Perception Survey)
MMEF
PRV/LE
Monthly MEDS Extract File
Provider/Legal Entity
SD/MC
Short-Doyle/Medi-Cal Claims
SDA
Statistics and Data Analysis
(aka Mental Health Analytics)
DHCS Branch Approver Certification:
I designate the above individuals to have independent authority to approve access requests to specific confidential mental
health patient data. DHCS-ITWS may rely on approvals, denials, and changes made by these individuals in its processing of
access requests to the above selected system(s). 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 "DHCSMHSDAPPCert@dhcs.ca.gov". Also,
I acknowledge reading
Letter No. 99-02
regarding Confidentiality of Client Information.
DHCS Branch Chief (Signature)
Printed
Date