Fillable State of California Health and H uman Services (Department of Health Care Services)

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State of California Health and H uman Services (Department of Health Care Services)

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State of California – Health and H uman Services Department of Health Care Services
Attachment A
APPLICATION FOR DHCS SITE REVIEW MASTER TRAINER CERTIFICATION
Initial Certification: Recertification: Date: _______________
Last Name: First Name: M.I.
Managed Care Health
Plan:
License Number:
Expiration Date:
Credentials:
MD
DO
PA
NP
RN
Trainings:
Date:
Summary of Course Content:
Instructor:
Site Reviews Completed in the past 12 months: Use extra sheet for additional sites
Site NPI
Number:
Provider Name:
Date:
FSR
and/or
MRR
Scores:
CAPs
Issued
(Y/N):
DHCS 8200 (Revised 03/2020) Page 1 of 4
State of California – Health and H uman Services Department of Health Care Services
Attachment A
APPLICATION FOR DHCS SITE REVIEW MASTER TRAINER CERTIFICATION
QI Experience in the last 5 years:
Date
Employer
Title and Primary Responsibilities
DHCS 8200 (Revised 03/2020) Page 2 of 4
Date
State of California – Health and H uman Services Department of Health Care Services
Attachment A
APPLICATION FOR DHCS SITE REVIEW MASTER TRAINER CERTIFICATION
DHCS Use ONLY:
Provider:
Family Practice
Pediatrics
OB/GYN
Gen. Practice
Internal Medicine
Provider Name and NPI Number:
Provider Address and Telephone Number:
Inter-Rater Date:
Findings:
Inter-Rater
Score:
MT Candidate
FSR:
MRR:
Inter-Rater
Score:
DHCS
FSR:
MRR:
Approved: Certificate Number:
Issue Date: Recertification Date:
Denied:
Please provide comments/actions/recommendations:
Completed By: Date:
DHCS 8200 (Revised 03/2020) Page 3 of 4
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signature
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State of California – Health and H uman Services Department of Health Care Services
Attachment A
APPLICATION FOR DHCS SITE REVIEW MASTER TRAINER CERTIFICATION
Site Reviews Completed:
Site NPI
Number
Provider Name
and NPI Number
Address Date
FSR and/or
MRR Score
CAPs
issued
DHCS 8200 (Revised 03/2020) Page 4 of 4
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State of California Health and H uman Services (Department of Health Care Services)

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Completed 6 April 2022

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