Fillable Department of Health Care Services (HSA)

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Department of Health Care Services (HSA)

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The Department of Health Care Services (HSA) form is 5 pages long and contains:

  • 3 signatures
  • 6 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

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State of California—Health and Human Services Agency
Department of Health Care Services
WILL LIGHTBOURNE GAVIN NEWSOM
DIRECTOR GOVERNOR
County-Based Medi-Cal Administrative Activities SPMP Questionnaire
Page 1 of 5
SKILLED PROFESSIONAL MEDICAL PERSONNEL (SPMP)
Questionnaire
Name of Employee:
Name of Employee’s Supervisor:
Name of Local Governmental Agency Coordinator:
To determine whether you qualify for federally funded reimbursement claims as an
SPMP, please complete the following questionnaire and return it to the Local
Governmental Agency (LGA) Coordinator no later than (Due Date: ).
Agency/Claiming Unit:
Position Classification:
Describe duties and list specific examples of how you use your medical knowledge or
skills to perform County-Based Medi-Cal Administrative Activities (CMAA) for the
claiming unit:
*Please add a separate page if additional space is needed.
County-Based Medi-Cal Administrative Activities SPMP Questionnaire
Page 2 of 5
1) Are you a physician licensed to practice medicine in the State of California?
a) YES.
i) Provide the license number:
ii) Attach a copy of your license, if available.
iii) Sign this form and return it.
b) NO. Proceed to Question 2.
2) Have you completed an educational program in a health-related field?
a) YES.
i) Which health-related field:
ii) Highest academic degree received in that field:
iii) Subject of your academic degree (Major):
iv) Name of the college/university where degree was obtained:
v) Attach a copy of your degree, if available.
b) NO. Proceed to Question 3.
3) Did your educational program last at least two years? Yes No
4) Did your educational program lead to a license in a medically related profession?
a) YES.
i) Provide the license type, number, and issuing state.
ii) Sign this form and return it.
iii) Attach a copy of your license, if available.
b) NO. Proceed to Question 5.
County-Based Medi-Cal Administrative Activities SPMP Questionnaire
Page 3 of 5
5) Did your educational program lead to a certification or registration by a recognized
National or California State health or health-related certifying organization?
a) YES.
i) Provide the Certification/Registration Type:
ii) Provide the Certification/Registration Number (if appropriate):
iii) Provide the name of the Certifying/Registration Organization:
iv) Sign this form and return it.
v) Attach a copy of your Certificate/Registration, if available.
b) NO. Proceed to Question 6.
6) Did part of your educational program involve medical or health-related training
including fieldwork (e.g., in health, mental health, or substance abuse)?
a) YES.
i) Describe the training/fieldwork:
ii) Sign the form and return it.
iii) Attach a copy of your certificates or documentation describing training, if
available.
b) NO. Proceed to Question 7.
County-Based Medi-Cal Administrative Activities SPMP Questionnaire
Page 4 of 5
7) As part of your educational program, did you take any courses that had a medical or
health-related focus (e.g., about health, mental health, or substance abuse)?
a) YES.
i) List the courses below:
ii) Sign the form and return it.
iii) Attach a copy of your certificates or documentation describing training, if
available.
b) NO. Proceed to Question 8.
8) How many years of experience do you have performing duties in a medically related
profession?
3 or more years 2 years 1 year Less than 1 year
a) Attach documentation of your experience, if applicable.
_____________________________________________ ________________
Signature of Claimant/Employee Date
Supervisor and LGA Coordinator’s Section
Supervisor’s statement of additional qualifying requirements for SPMP status:
LGA Coordinator’s recommendations:
_________________________________________________ ________________
Signature of LGA Coordinator’s Date
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County-Based Medi-Cal Administrative Activities SPMP Questionnaire
Page 5 of 5
CMAA Program Staff Section
I have reviewed the SPMP Questionnaire and the attached documentation and have
determined:
The Claimant/Employee meets the essential requirements of an SPMP.
The Claimant/Employee does not meet the essential requirements of an SPMP.
______________________________________________ ________________
Signature of CMAA Program Staff Date
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Department of Health Care Services (HSA)

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Completed 21 February 2021

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