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: Address: Date: FSR and/orMRR 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

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

Last Name: First Name: Managed Care Health Plan: MD: OffDO: OffPA: OffNP: OffRN: OffProvider Name and NPI Number: Provider Address and Telephone Number: Approved: OffDenied: OffDate: M: I:

License Number: License Expiration Date: Summary of Course Content 1: Course Date 1: Course Instructor 1: Course Date 2: Summary of Course Content 2: Course Instructor 2: Course Date 3: Course Date 4: Summary of Course Content 3: Summary of Course Content 4: Course Instructor 3: Course Instructor 4: Provider Name 1: Site NPI Number 2: Site NPI Number 3: Site NPI Number 4: Site NPI Number 5: Site NPI Number 6: Site NPI Number 7: Site NPI Number 8: Site NPI Number 9: Site NPI Number 10: Provider Name 2: Provider Name 3: Provider Name 4: Provider Name 5: Provider Name 6: Provider Name 7: Provider Name 8: Provider Name 9: Provider Name 10: Address 2: Address 3: Address 4: Address 5: Address 6: Address 7: Address 8: Address 9: Address 10: Site Review Date 2: Site Review Date 3: Site Review Date 4: Site Review Date 5: Site Review Date 6: Site Review Date 7: Site Review Date 8: Site Review Date 9: Site Review Date 10: FSR and/or MRR Scores 1: FSR and/or MRR Scores 2: FSR and/or MRR Scores 3: FSR and/or MRR Scores 4: FSR and/or MRR Scores 5: FSR and/or MRR Scores 6: FSR and/or MRR Scores 7: FSR and/or MRR Scores 8: FSR and/or MRR Scores 9: FSR and/or MRR Scores 10: CAPs Issued (Y/N) 1: CAPs Issued (Y/N) 2: CAPs Issued (Y/N) 3: CAPs Issued (Y/N) 4: CAPs Issued (Y/N) 5: CAPs Issued (Y/N) 6: CAPs Issued (Y/N) 7: CAPs Issued (Y/N) 8: CAPs Issued (Y/N) 9: CAPs Issued (Y/N) 10: QI Experience Date 2: QI Experience Date 3: QI Experience Date 4: QI Experience Date 5: QI Experience Date 6: QI Experience Date 1: Employer 1: Employer 2: Employer 3: Employer 4: Employer 5: Employer 6: Title and Primary Responsibilities 1: Title and Primary Responsibilities 2: Title and Primary Responsibilities 3: Title and Primary Responsibilities 4: Title and Primary Responsibilities 5: Title and Primary Responsibilities 6: Family Practice: OffPediatrics: OffOB/GYN: OffGeneral Practice: OffInternal Medicine: OffInter-Rater Findings: Inter-Rater Date: MT Candidate FSR: MT Candidate MRR: DHCS FSR: DHCS MRR: Certificate Number: Issue Date: Recertification Date: Denied: Please provide comments/actions/recommendations: Signature Date: Number of Site Reviews Completed: Site NPI Number 11: Site NPI Number 12: Site NPI Number 13: Site NPI Number 14: Site NPI Number 15: Site NPI Number 16: Site NPI Number 17: Site NPI Number 18: Site NPI Number 1: Site NPI Number 19: Provider Name and NPI Number 11: Provider Name and NPI Number 12: Provider Name and NPI Number 13: Provider Name and NPI Number 14: Provider Name and NPI Number 15: Provider Name and NPI Number 16: Provider Name and NPI Number 17: Provider Name and NPI Number 18: Provider Name and NPI Number 19: Address 11: Address 12: Address 13: Address 14: Address 15: Address 16: Address 17: Address 18: Address 1: Address 19: Site Review Date 11: Site Review Date 12: Site Review Date 13: Site Review Date 14: Site Review Date 15: Site Review Date 16: Site Review Date 17: Site Review Date 18: Site Review Date 1: Site Review Date 19: FSR and/or MRR Score 11: FSR and/or MRR Score 12: FSR and/or MRR Score 13: FSR and/or MRR Score 14: FSR and/or MRR Score 15: FSR and/or MRR Score 16: FSR and/or MRR Score 17: FSR and/or MRR Score 18: FSR and/or MRR Score 19: CAPs issued 11: CAPs issued 12: CAPs issued 13: CAPs issued 14: CAPs issued 15: CAPs issued 16: CAPs issued 17: CAPs issued 18: CAPs issued 19: Certification: Radio: Off