Fillable OUTPATIENT INFANT HEARING SCREENING PROVIDER APPLICATION (Department of Health Care Services)

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OUTPATIENT INFANT HEARING SCREENING PROVIDER APPLICATION (Department of Health Care Services)

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The OUTPATIENT INFANT HEARING SCREENING PROVIDER APPLICATION (Department of Health Care Services) form is 2 pages long and contains:

  • 1 signature
  • 7 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

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State of California—Health and Human Services Agency
Department of Health Care Services
California Children’s Services
OUTPATIENT INFANT HEARING SCREENING PROVIDER APPLICATION
Name of facility/individual
Name of administrator
Medi-Cal provider number NPI number
Service address City ZIP code County
Telephone number FAX
Mailing address (if different from above) City State ZIP code
Contact person for this application
Telephone number FAX E-mail
TYPE OF FACILITY (check one)
Newborn Hearing Screening Program-approved Inpatient Infant Hearing Screening Provider
California Children’s Services-approved Hearing and Speech Center
Ambulatory health care facility or provider office (If checked, please complete the following.)
Individual responsible for supervision of outpatient infant hearing screening services:
CCS-Paneled Pediatrician
CCS-Paneled ENT
CCS-Paneled Family Practice Physician
CCS-Paneled Audiologist
TYPE OF HEARING SCREENING EQUIPMENT TO BE USED (for newborns and infants):
TEOAE DPOAE
Automated ABR ABR
Other
Manufacturer Model Serial Number
Please attach a copy of the documentation from manufacturer that the equipment can detect a mild, 30–40 dB, hearing loss.
DHCS 4481 (2/08)
STAFFING
Name of the person responsible for overseeing the outpatient infant hearing screening services (Please attach a copy of the Curriculum Vitae.)
List the names and positions of all personnel who will perform screenings:
Name Position
Name Position
Name Position
Name Position
Name Position
Name of the person responsible for training (Submit Curriculum Vitae and indicate when/how individual was trained on infant hearing screening equipment)
This application is submitted with the understanding that the facility/individual will comply with the terms contained in
Standards for Outpatient Infant Hearing Screening Providers, Chapter 3.42.2. In addition, the facility/individual will provide
documentation of procedures the facility will use to support the activities identified in Sections C.4 Care Coordination/Referral
and C.5 Reporting Requirements, if requested. The signature below certifies that the facts in this application are true and
correct to the best of the signator’s knowledge.
Authorized Signature
Title Date
MAIL THE COMPLETED APPLICATION AND ALL NECESSARY DOCUMENTS TO:
Attention: Unit Manager
Hearing and Audiology Services Unit
Children’s Medical Services Branch, MS 8103
Department of Health Care Services
P.O. Box 997413
Sacramento, CA 95899-7413
DHCS 4481 (2/08)
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OUTPATIENT INFANT HEARING SCREENING PROVIDER APPLICATION (Department of Health Care Services)

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Completed 23 November 2020

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