Form Dhcs 5102 - California Caloms Itws County/direct Provider/vendor User Cancellation - Health And Human Services Agency
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1State of California — Health and Human Services Agency
Department of Health Care Services
CalOMS
MS 2603
PO Box 997413
Sacramento, CA 95899-7413
CalOMS ITWS County/Direct Provider/Vendor User Cancellation
DHCS Approved
Date
Approver
For Canceling User Access to the CalOMS Treatment Data System
County or Direct Provider or Vendor Name:
County or Direct Provider or Vendor Number:
To ensure the confidentiality of county/direct provider CalOMS Treatment data, the Department of Health Care Services (DHCS)
requires that the County Alcohol and Drug Program Administrator or Direct Provider/Vendor Executive Officer notify DHCS when
previously-approved users should no longer be allowed access to confidential patient data in the CalOMS Treatment data system.
Please complete and fax this form to DHCS at (916) 322-7117. If you have questions about this form, please call (916) 327-3010 or e-
mail CalOMSHelp@DHCS.ca.gov
Please print all information
First Name:
Last Name:
Username:
Phone Number: (
)
Fax Number: : (
)
Email Address:
User no longer authorized access as of _________________(date) to the CalOMS Treatment data system.
First Name:
Last Name:
Username:
Phone Number: (
)
Fax Number: : (
)
Email Address:
User no longer authorized access as of _________________(date) to the CalOMS Treatment data system.
First Name:
Last Name:
Username:
Phone Number: (
)
Fax Number: : (
)
Email Address:
User no longer authorized access as of _________________(date) to the CalOMS Treatment data system.
County AOD Administrator/Direct Provider or Vendor Executive Officer:
I hereby designate that the above-named individual(s) no longer has access rights to confidential patient data in the CalOMS
Treatment data system
____________________________________________________________
__________________________________
Administrator/Executive Officer
(signed and printed)
Date
DHCS 5102 (06/13)
ADP 100180 (06/13)
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