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uI POLICY/PROCEDURE DEPARTMENT OF MENTAL …

%. O: LOS1. DEPARTMENT OF MENTAL health . uI POLICY/PROCEDURE . 4 CIForL'. SUBJECT POLICY NO. EFFECTIVE PAGE. DATE. REQUEST FOR CHANGE OF 06/18/2018 1 of 5. PROVIDER. APPROVED BY: SUPERSEDES ORIGINAL DISTRIBUTION. 2 1v-1. ISSUE DATE LEVEL(S). 5_' %. Director 08/29/2016 01/01/2003 1, 2. 1. P4 WPOSE. 1 .1 Provide a formal process for beneficiaries to request a change in program of service or rendering staff. 1 .2 Comply with the California DEPARTMENT of health Care Services (DHCS), MENTAL health Services Division's (MHSD) requirement that Local MENTAL health Plans (LMHP5) submit a summary report of voluntary change of provider requests from Medi-Cal beneficiaries seen through the LMHP. (Authorities 1 2, 3, 4, and 5). , DEFINITION. Provider: Person or entity who is licensed, certified, or otherwise recognized or authorized under state law governing the healing arts to provide specialty MENTAL health services and who meets the standards for participation in the Medi-Cal program.

o: los1 department of mental health ui policy/procedure ‘4ciforl’ subject policy no. effective page date request for change of 200.05 06/18/2018 1 of 5

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