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Search results with tag "Chdp provider data sheet"
California Child Health and Disability Prevention (CHDP ...
www.dhcs.ca.govReviewed by CHDP Director (print name) Signature Date signed Date CHDP Provider Data Sheet (PM 177) sent to State DHCS 4490 (01/08) Page 1 of 4 . 16. Clinical Laboratory Improvement Amendment (CLIA) (check one): CLIA waiver …
CHDP PROVIDER DATA SHEET
www.dhcs.ca.govB. - Change - Enter code “B” when there is a change to the name, address, phone, email, category, CLIA, tax ID or provider type. C. - Inactivate - Enter code “C” when inactivating a legacy provider number/ NPI or a single location that has more than one location under the same NPI.