Fillable Directory Template ADA SPECIAL CARE CENTER (SCC) DIRECTORY UPDATE FAX COVER SHEET

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Directory Template ADA SPECIAL CARE CENTER (SCC) DIRECTORY UPDATE FAX COVER SHEET

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__________________________________________ _____________________________________________
State of California – Health and Human Services Agency Department of Health Care Services
SPECIAL CARE CENTER (SCC) DIRECTORY UPDATE
COVER SHEET
To: Provider and Facility Site Review Unit
E-mail: CCSFacilityData@dhcs.ca.gov
Date: ___________________________________
Medical Director (Print)
Contact person: ______________________________
Facility name: ________________________________
SCC #: ______________________________________
Phone: ______________________________________
Total pages: __________________________________
Medical Director (Signature)
INSTRUCTIONS
1. Find and print your SCC directory listing in the Special Care Center section of the CCS website
www.dhcs.ca.gov.services/ccs
.
2. Fill in the changes (including additions or removals of staff) directly on your SCC directory listing. Please ensure you
provide the NPI number, as there are many similar names.
3. If staff have been added to or removed from your SCC directory listing, supply their active Provide Number,
discipline, and effective date(s) using the table below.
STAFF NAME
(Last Name, First Name)
DISCIPLINE
(i.e. Pediatric
Cardiology)
STAFF NPI
and/or LICENSE
NUMBER
ACTION
EFFECTIVE DATE
(MM/DD/YY)
Add Remove
Add Remove
Add Remove
Add Remove
Add Remove
Add Remove
Add Remove
Add Remove
Add Remove
Add Remove
4. Complete the top portion of this cover sheet. The Medical Director must sign this cover sheet.
5. E-mail the completed cover sheet and your edited SCC directory listing to CCSFacilityData@dhcs.ca.gov
6. Updates are made routinely. Changes are posted on the CCS website at the end of each workweek.
DHCS4507 (01/08)
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Directory Template ADA SPECIAL CARE CENTER (SCC) DIRECTORY UPDATE FAX COVER SHEET

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Completed 3 July 2020

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