HomeMy WebLinkAboutAgreement A-17-392 with Ca. Dept. of Health Care Svc's..pdfCalifornia Department of Social Services
Research Services Branch
Child Welfare Data Analysis Bureau
California Department of Social Services , Department of Health Care Services
and County/Tribe Global Memorandum of Understanding (MOU) 15-00576
County/Tribe Authorized Requesters
Indicate below the staff in your county who are authorized to submit data requests pursuant to the
Global MOU 15-00576. Please submit this form to : CWSData@dss .ca .gov.
County _Fresno ______________ _
Requestor Name E-Mail Phone No
Jessica Carrillo carrijb@co .fresno .ca .us (559) 600-2355
Approved By Authorized Signatory: __ l_--~-~---· , __________ .....:l...1,D:::;__-..:...;IO=---....:.J.....:7_
Printed Name and Title : Brian Pacheco
Chairman , Board of Supervisors
As of 6/26/2015
ATTEST:
BERNICE E. SEIDEL, Clerk
Board of Supervi sors
By SuSl'vn &$be'()
Deputy
California Deparlment of Social Services
Research Services Branch
Child Welfare Data Analysis Bureau .
California Department of Social Services, Department of Health Care Services, and County/Tribe
Memorand-um of Understanding (MOU) Global 15-00576 or Psychotropic Medications ·16-6009 ..
SafeMeasures Medi.;.Cal Administrator Designation Form
. . . . . ' .
· • Please designate between one to three county staff as SafeMeasures Medi;..Cal Administrators whose.
role is to disseminate access of Medi-Cal reports in SafeMeasures byass.igning appropriate county
staff as Medi.,Cal Users or My Upcoming Work Users pursuanttoACIN 1-27-17. · ·
·Although not required, we recommend that the same county staff have both roles as Authorized·.
Requestor (for F'ile Transfer) and SafeMeasures Medi:..Cal Administrator.
Please submit the completed and signed form to: CWSDafa@dss.ca.gov
County Name: _· _FRESNO __ ---., __ ___;, __ _
.In order to become a Medi-Cal Administrator, users are required to have SafeMeasures ·
Administrator rights: If necessary, please contact your SafeMeasures Administrator to. create arid/or
upgrade your account before submitting this form.
Name E-mail·
1 Jessica Carrillo. carrijb@coJresno.ca; us
2. Brenda Elkins · BDunla~@co.fresno.ca.us
-........ . -'
. .
"3 Mathew Ca_lvillo . MCalvillo@co.fresno.ca.us
· Please ensure that Authorized Signatory on this form matches the Signatory found-on your county's MOU. 1 . . . . . . . .
Approved by Authorized Signatory
. Signature of Authorized Signatory
Brian Pacheco, Chairman, Board of Supervisors
Name and Title ·
Date: Ddti~2.5" ~d.· . I .
ATTEST:
BERNICE E. SEIDEL
Clerk to the Board of Supervisors
Cou~t~ of Fresno, State of California
,BY~Lct#, ~
Revised 9/27/2017