State of California – H ealth and Human Services Agency ... Document Library... · 2. cpsp provider overview training staff title of date of planned /scheduled name training training

Date:

State of California – Health and Human Services Agency California Department of Public Health

Legal Name of Applicant:

National Provider Identifier:

CDPH 4448A (7/18)

1. ADDI TION AL PR ACTI TI ONERS PROVIDI NG CPSP SERVICES

(A) (C) (D) (E) PRACTITIONER NAME PRACTITIONER QUALIFICATIONS SERVICE(S) PROVIDED* YRS

OF

(B) CPSP PRACTITIONER TYPE

(MD/DO, CNM, NP, PA, LM, RN, LVN, SW, PSY, MFT, RD, HE, CCE, CPHW) OB B CO HE N PSY CC CON P EXP.

LIC/CERT/REG#: _____________________________ SCHOOL: __________________________________ DEGREE: ______________________ YEAR: _______










* OB = Obstetrics/Gynecology B = Back-Up Physician CO = Client Orientation HE = Health Education N = Nutrition PSY = Psychosocial CC = Case Coordination CON = Consultation P = Protocol Approval

ADDITIONAL CPSP PRACTITIONERS

Legal Name of Applicant: Date:

National Provider Identifier:

2. CPSP PROVIDER OVERVIEW TR AI NINGSTAFF TITLE OF DATE OF PLANNED/SCHEDULED NAME TRAINING TRAINING TRAINING DATE

CDPH 4448A (7/18)

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State of California – H ealth and Human Services Agency ... Document Library... · 2. cpsp provider overview training staff title of date of planned /scheduled name training training