State of California—Health and Human Services Agency Department of Health Care Services
Children’s Medical Services (CMS) Branch
DHCS 4510 (Rev 05/13)
INSTRUCTIONS
County: The name of the county submitting request.
Select One:
Add: Select check box if adding a therapist to a MTU.
Modify: Select check box if modifying an existing therapist assignment.
Delete: Select check box if deleting therapist from all MTUs.
Position: Select position(s) of therapist.
OT: Occupational Therapy (OT)
PT: Physical Therapy (PT)
Aide/Asst. for PT: Aide/Assistant for PT
Aide/Asst. for OT: Aide/Assistant for OT
Name (Last, First): Type therapist’s last name, then therapist’s first name.
MTU Action:
Add to: Select check box if adding therapist to MTU
Inactive from: Select check box if removing therapist from MTU
MTU Name: Name of the Medical Therapy Unit.
Requestor’s Name (Print): Type the name of person submitting request.
Phone: Type the requestor’s phone number, including area code (and extension if applicable) in format
(999)999-9999.
Requestor’s Title: Title of requestor.
Date: Date of request.
