State of California—Health and Human Services Agency Department of Health Care Services
Integrated Systems of Care Division (ISCD)
INSTRUCTIONS
County/Local Program: The name of the county or local program submitting request.
Select One:
Add: Select check box if this request is for account activation.
Modify: Select check box if this request is for account modification.
Delete: Select check box if this request is for account deactivation.
Access:
CCS: Select check box for access to create/view/modify CCS reports.
CHDP: Select check box for access to create/view/modify CHDP reports.
GHPP: Select check box for access to create/view/modify GHPP reports.
Name (Last, First) and Email: Type user’s last name, then user’s first name and user’s email address.
Phone: Type user’s phone number, including area code (and extension if applicable) in format
(999)999-9999.
Address: Type the work address of the users listed above. Include number, street, suite number,
city or town, state, and ZIP code. If more than one location, list the primary work address
of the office or use a different form for each address.
Representative’s Name (Print): Type the name of the person submitting request. Representative must be a State ISCD
Branch manager, CCS/CMS Administrator, CHDP Director, or CHDP Deputy Director.
Phone: Type the representative’s phone number, including area code (and extension if
applicable) in format (999)999-9999.
Representative’s Name (Signature): Signature of representative.
Date: Date account request was signed by the representative.
County/Local Program: The name of the county or local program submitting request.
Printed Name of Staff: Name of user(s) with the “Add” option selected. Each user with the “Add” option selected
must be listed.
Staff Signature: Signature of user(s) with the “Add” option selected. Each user with the “Add” option
selected must sign the confidentiality oath.
Date: Date user(s) with “Add” option selected signed the form.
DHCS 4074 (Rev 08/18) Page 3 of 3
