Form Dhcs 5099 - California Caloms Tx Itws County/direct Provider Approver Form - 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 Tx ITWS County/Direct Provider Approver Form
DHCS Approved
For Granting Access to the CalOMS Treatment Data System
Date
Approver
County or Direct Provider Name:
County or Direct Provider Number:
To ensure the confidentiality of county/direct provider CalOMS Treatment data, the Department of Health Care Services (DHCS)
requires that each County Alcohol and Drug Program Administrator or Direct Provider Executive Officer designate a primary and a
secondary contact to be responsible for approving county/direct provider staff requests for ITWS 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
Primary Approver (person who approves enrollment form):
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: (
)
Email Address:
Primary Approver’s Signature:
(Signer acknowledges having read the attached Confidentiality Statement to Users of the Information Technology Web Services (ITWS))
Secondary Approver (person who approves enrollment form):
First Name:
Last Name:
Title:
Phone Number: (
)
Fax Number: (
)
Email Address:
Secondary Approver’s Signature:
(Signer acknowledges having read the attached Confidentiality Statement to Users of the Information Technology Web Services (ITWS))
Appointed Vendor(s):
(If applicable)
The vendor listed below has the authority to receive, send and process the above-named county/direct provider’s confidential CalOMS
Treatment information as marked below. The vendor will establish its own primary and secondary approving contacts by completing
the Vendor Approver Certification form (DHCS 5100).
Vendor Name:
Vendor Contact Name:
Phone Number: (
)
County AOD Administrator/Direct Provider Executive Officer Approval:
I hereby approve the above-named individual(s) and vendor, if applicable, to have independent authority to approve access to ITWS
confidential CalOMS Treatment patient data.
DHCS may rely on approvals, denials, and changes made by the above
individual(s)/vendor in its processing of county/direct provider’s data in the systems listed above. As changes occur to the above contacts
or vendor information (name, phone, e-mail), I will complete a new approver form and forward it to DHCS. Also, I acknowledge reading
the Confidentiality Statement to Users of the Information Technology Web Services (ITWS).
____________________________________________________________
__________________________________
Administrator/ Executive Officer
(signed and printed)
Date
DHCS 5099 (06/13)
ADP 100177 (06/13)
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