Fillable Dhcs9093 CMS County System Administrators Oath

Fill Online, Printable, Fillable, Blank Dhcs9093 CMS County System Administrators Oath Form

Use Fill to complete blank online DEPARTMENT OF HEALTH CARE SERVICES (CALIFORNIA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Dhcs9093 CMS County System Administrators Oath

On average this form takes 2 minutes to complete

The Dhcs9093 CMS County System Administrators Oath form is 1 page long and contains:

  • 0 signatures
  • 2 check-boxes
  • 7 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Department of Health Care Services (California) forms online.

BROWSE DEPARTMENT OF HEALTH CARE SERVICES (CALIFORNIA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
State of California – Health and Human Services Agency Department of Health Care Services
Children’s Medical Services (CMS) Branch
DHCS 9093 (Rev 05/13)
CMS NET COUNTY SYSTEM ADMINISTRATOR
SECURITY AND CONFIDENTIALITY OATH
Submit Form: Fax: (916) 440-5346 or
Scan and email: cmshelp@dhcs.ca.gov
Questions? Contact the CMS Net Help Desk
(866) 685-8449 or cmshelp@dhcs.ca.gov
This form is to add a CMS Net user as a County System Administrator or County System Administrator Plus. Please
type or print legibly.
County:
Mark one type of access- County System Administrator or County System Administrator Plus.
_____ County System Administrator
1. Add, deactivate or reactivate users
2. Reset user passwords
3. Modify/assign user security profiles
4. Modify/Reauthorize Cancelled SAR
5. Modify historical referral/transfer dates
6. Edit permanently assigned case numbers
7. End date Healthy Families Plans
_____ County System Administrator Plus
All above County System Administrator capabilities plus:
8. Correct program eligibility dates
9. Correct client eligibility closures/denials
10. Access transaction tracking to determine who last updated a particular record
Read the agreement items listed below and sign your initials if you agree to each.
_____ I will not divulge or share in any users’ personal information including, but not limited to passwords and
access codes to individuals who are not a designated CMS State or County System administrators.
_____ I will not abuse or misuse the privileges as a County System administrator.
_____ I will not create any unnecessary user security profiles such as fake, generic, or pseudo accounts.
_____ I understand that the Department of Health Care Services, Children’s Medical Services Branch has the
right to remove and revoke users’ and counties’ access to have County System administrator privileges
at any time for any or no reason at all.
_____ I will follow and adhere to the CMS User Security procedures and guidelines for County System
administrators outlined above.
Applicant’s Name (Last, First):
Title:
Phone:
Applicant’s Name (Signature):
Date:
Representative’s Name (Print):
Phone:
Representative’s Name (Signature):
Date:
State of California – Health and Human Services Agency Department of Health Care Services
Children’s Medical Services (CMS) Branch
DHCS 9093 (Rev 05/13)
INSTRUCTIONS
County: The name of the county submitting request.
Mark one type of access:
County System Admin User can:
1. Add, deactivate or reactivate users
2. Reset user passwords
3. Modify/assign user security profiles
4. Modify/Reauthorize Cancelled SAR
5. Modify historical referral/transfer dates
6. Edit permanently assigned case numbers
7. End date Healthy Families Plans
Co System Admin-Plus User can perform all above County System Administrator capabilities plus:
8. Correct program eligibility dates
9. Correct client eligibility closures/denials
10. Access transaction tracking to determine who last updated a particular record
Applicant’s Name (Last, First): Type applicant’s last name, then applicant’s first name.
Title: The applicant’s title.
Email Address: Type the applicant’s email address.
Phone: Type the applicant’s phone number, including area code (and extension if applicable) in
format (999)999-9999.
Applicant’s Name (Signature): Signature of applicant.
Date: Date account request was signed by the applicant.
Representative’s Name (Print): Type the name of person submitting request. Representative must be a California
Children’s Services (CCS) Administrator.
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.
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Dhcs9093 CMS County System Administrators Oath

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 3 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document