Fillable Dhcs4087 Master index Rejection Notice

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Dhcs4087 Master index Rejection Notice

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_____________________________________________________ ________________
_____________________________________________________ ________________
State of California—Health and Human Services Agency Department of Health Care Services
California Children’s Services (CCS)
MASTER INDEX REJECTION NOTICE
Program Support Section
P.O. Box 997413
(Coding hints: No Decimals—No Spaces)
Sacramento, CA 95899-7413
Please submit the needed information requested below to CCS Headquarters. Thank you.
(916) 327-1400
1. More specific code 10. Correct form
❒ ❒
2. Code for each diagnosis 11. Correct state file number
❒ ❒
3. Five digit ICD-9 Code
❒
4. Underlying and/or primary diagnosis code
❒
5. Medically eligible diagnosis code
❒
6. Code to reason for V code
❒
7. Correct/full name
❒
8. Correct birth date
❒
9. New state file number (The attached number has been assigned to another patient.)
❒
12. Complete information
❒
13. “Notice of Change of Information,” DHS 4015
❒
14. Copy of original “Report of Case Opened” (if original does not contain
❒ information currently required, also submit current “Report of Case Opened.”
Use old state file number.)
15. “Report of Case Closure,” DHS 4015
❒
16. Other
❒
Initiated by:
CCS Headquarters Master Index Unit Date
DHCS 4087 (06/07)
State of California—Health and Human Services Agency Department of Health Care Services
California Children’s Services (CCS)
MASTER INDEX REJECTION NOTICE
Program Support Section
P.O. Box 997413
(Coding hints: No Decimals—No Spaces)
Sacramento, CA 95899-7413
Please submit the needed information requested below to CCS Headquarters. Thank you.
(916) 327-1400
1. More specific code 10. Correct form
❒ ❒
2. Code for each diagnosis 11. Correct state file number
❒ ❒
3. Five digit ICD-9 Code
❒
4. Underlying and/or primary diagnosis code
❒
5. Medically eligible diagnosis code
❒
6. Code to reason for V code
❒
7. Correct/full name
❒
8. Correct birth date
❒
9. New state file number (The attached number has been assigned to another patient.)
❒
12. Complete information
❒
13. “Notice of Change of Information,” DHS 4015
❒
14. Copy of original “Report of Case Opened” (if original does not contain
❒ information currently required, also submit current “Report of Case Opened.”
Use old state file number.)
15. “Report of Case Closure,” DHS 4015
❒
16. Other
❒
Initiated by:
CCS Headquarters Master Index Unit Date
DHCS 4087 (06/07)
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Completed 3 July 2020

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