Form DHCS7201 "County Approver Certification for Access to the Department of Health Care Services Cost and Financial Reporting System (Cfrs)" - California

What Is Form DHCS7201?

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 September 1, 2019;
  • 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 DHCS7201 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 DHCS7201 "County Approver Certification for Access to the Department of Health Care Services Cost and Financial Reporting System (Cfrs)" - California

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State of California – Health and Human Services Agency
Department of Health Care Services
County Approver Certification Form
For Access to the Department of Health Care Services Cost and Financial Reporting System
(CFRS).
County Name: __________________________________________________________
To ensure the confidentiality of county mental health data, the Department of Health Care Services,
requests the county Behavioral Health Director designate two contacts to be responsible for
approving county staff requests for access to the confidential data in CFRS system.
Please complete the information below and email the signed form to MedCCC@dhcs.ca.gov. The
email must be sent from the signer’s (Behavioral Health Director’s) email account. If you have any
questions, please email MedCCC@dhcs.ca.gov.
Approver 1:
First
Last
Name:
Name:
Title:
Fax
Phone Number:
Number:
Email
Address:
Signature:
Date:
Approver 2:
First
Last
Name:
Name:
Title:
Fax
Phone Number:
Number:
Email
Address:
Signature:
Date:
County Behavioral Health Director Certification:
I, the undersigned designate the above county individuals to have independent authority to approve
access requests to the Cost and Financial Reporting System (CFRS). DHCS may rely on
approvals, denials, and changes made by the above individuals in its processing of access requests
to this county’s data. As changes occur to the above approving county contacts, I will sign an updated
certification and forward it to DHCS.
By submitting this form, any previous approvers will be deleted.
County Behavioral Health Director Signature
Date
County Behavioral Health Director Name
County Behavioral Health Director Email
Address
DHCS 7201 (09/19)
State of California – Health and Human Services Agency
Department of Health Care Services
County Approver Certification Form
For Access to the Department of Health Care Services Cost and Financial Reporting System
(CFRS).
County Name: __________________________________________________________
To ensure the confidentiality of county mental health data, the Department of Health Care Services,
requests the county Behavioral Health Director designate two contacts to be responsible for
approving county staff requests for access to the confidential data in CFRS system.
Please complete the information below and email the signed form to MedCCC@dhcs.ca.gov. The
email must be sent from the signer’s (Behavioral Health Director’s) email account. If you have any
questions, please email MedCCC@dhcs.ca.gov.
Approver 1:
First
Last
Name:
Name:
Title:
Fax
Phone Number:
Number:
Email
Address:
Signature:
Date:
Approver 2:
First
Last
Name:
Name:
Title:
Fax
Phone Number:
Number:
Email
Address:
Signature:
Date:
County Behavioral Health Director Certification:
I, the undersigned designate the above county individuals to have independent authority to approve
access requests to the Cost and Financial Reporting System (CFRS). DHCS may rely on
approvals, denials, and changes made by the above individuals in its processing of access requests
to this county’s data. As changes occur to the above approving county contacts, I will sign an updated
certification and forward it to DHCS.
By submitting this form, any previous approvers will be deleted.
County Behavioral Health Director Signature
Date
County Behavioral Health Director Name
County Behavioral Health Director Email
Address
DHCS 7201 (09/19)