OLIVE VIEW-UCLA MEDICAL CENTER Medical Administration

INTEROFFICE MEMORANDUM

DATE: _____________________ TO: Medical Staff Office FROM: _____________________ _____________________ RE: 2019/2020 HOUSE STAFF MEMBER CHECKLIST The attached HOUSE STAFF INFORMATION SHEET is for: LAST FIRST M.I. Department: Specialty: C#: County Title (Select One)

� Intern w/o Comp (9439) � Phys. Post Grad. 1st Yr. (5408)

� Resident w/o Comp (9440) � Phys. Post Grad. 2nd-7th Yr. (5411) This APPLICABLE DOCUMENTATION MUST ACCOMPANY this form: House Staff Information Sheet � Attached

Copy of Medical School Diploma � Attached

Copy of E.C.F.M.G. Certificate (Foreign Graduate Physician Only)

� Attached � Not Applicable

O:Carol:Residentapplication19/20

OLIVE VIEW-UCLA MEDICAL CENTER HOUSE STAFF INFORMATION SHEET

(Please complete BOTH SIDES of this form)

Are you currently in an ACGME (Accreditation Council for Graduate Medical Education) Program? � Yes (If “yes,” proceed with this information sheet) � No (If “no,” stop. Complete a PSA {Professional Staff Association} Application) Last, First, Middle

Print or type full name, including suffix (e.g., Jr., Sr.) and maiden name if applicable ACADEMIC YEAR 2019/2020

Home Address City State Zip Telephone Number ( )

Beeper/Pager Number ( )

E-mail address:

• I hold the following valid State of California License:

� Physician and Surgeon Number: _________________ Expiration Date: _____ / _____ / _____

� D.O. Number: _________________ Expiration Date: _____ / _____ / _____

� D.D.S. Number: _________________ Expiration Date: _____ / _____ / _____

• I hold the following Drug Enforcement Administration Certificate (� I do not possess a DEA Certificate):

Number: _________________ Expiration Date: _____ / _____ / _____

• Attached is a coy of my E.C.F.M.G. Certificate (� Not Applicable): Number: ________________ Date Issued: ____ / ____ / ____ Expiration Date: _____ / _____ / _____

• Ethnicity:___________________________ Languages Spoken:__________________________________

• My Social Security Number is: ______--______--______. • Please indicate: � Male � Female

• My NPI Number is ___________________ (10 digits)

• My Date of Birth is: ______ / ______ / ______, and Place of Birth: ____________________________ (City and State/Country)

AMERICAN BOARD OF MEDICAL SPECIALTIES CERTIFICATION(S). Attach copies of all board certifications. Indicate here if not presently Board Certified: �

American Board Name Expected Date of Examination

Date Certified (Mo / Yr)

Date Recertified (To be Recertified)

(Mo / Yr) (1)

(2)

MEDICAL EDUCATION List the name(s) of all medical/osteopathic school(s) attended, city and state, beginning and ending dates, degree received and the date the degree was received. (Attach a copy of your ECFMG certificate if you received your medical education outside of the United States)

Name of School

Address

Complete Street, City, State, Zip Code

From

TO

(mm/dd/yy)

Degree

Received (1)

___ / ___ / ___

(2)

___ / ___ / ___

Page 1 o:carol:Residentapplication19/20

POSTGRADUATE TRAINING AND EXPERIENCE INTERNSHIP/PGY1 Attach additional sheets if necessary. Institution:

Program Director:

Mailing Address:

City:

State & Country: ZIP:

Type of Internship: Specialty: From: (mm/yy) To: (mm/yy)

RESIDENCIES/FELLOWSHIPS Include residencies, fellowships, preceptorships in chronological order, giving name, address, city and ZIP code, and dates. Include all programs you attended, whether or not completed. (Attach additional sheets if necessary). Institution:

Program Director:

Mailing Address:

City:

State & Country: ZIP:

Type of Training (e.g. Residence, etc.): Specialty: From: (mm/yy) To: (mm/yy)

Did you successfully complete the program? � Yes � No (If “No,” please explain on separate sheet.) Institution:

Program Director:

Mailing Address:

City:

State & Country: ZIP:

Type of Training (e.g. Residence, etc.): Specialty: From: (mm/yy) To: (mm/yy)

Did you successfully complete the program? � Yes � No (If “No,” please explain on separate sheet.) Institution:

Program Director:

Mailing Address:

City:

State & Country: ZIP:

Type of Training (e.g. Residence, etc.): Specialty: From: (mm/yy) To: (mm/yy)

Did you successfully complete the program? � Yes � No (If “No,” please explain on separate sheet.)

Page 2 o:carol:Residentapplication19/20

ATTESTATION QUESTIONS: Please read and answer each question carefully. Any discrepancies or inaccuracies may be used to reject the application, or to revoke membership upon discovery of the discrepancy or inaccuracy. Please answer the following questions “yes” or “no.” If your answer to question A is “no,” or if your answer to B through O is “yes,” please provide full details on separate sheet. (A) Are you able to perform all the services required by your agreement with, or the professional staff bylaws of, the Healthcare Organization to which you are applying, with or without reasonable accommodation, according to accepted standards of professional performance and without posing a direct threat to the safety of patients?

� Yes � No

(B) Has your license to practice medicine in any jurisdiction, your Drug Enforcement Administration (DEA) registration or any applicable narcotic registration in any jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have to voluntarily or involuntarily relinquished any such license or registration or voluntarily or involuntarily accepted any such actions or conditions, or have you been fined or received a letter of reprimand or is such action pending?

� Yes � No

(C) Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subjected to probationary conditions, restricted or excluded, or have you voluntarily or involuntarily relinquished eligibility to provide services or accepted conditions on your eligibility to provide services, for reasons relating to possible incompetence or improper professional conduct, or breach of contract or program conditions, by Medicare, Medicaid, or any public program, or is any such action pending?

� Yes � No

(D) Have your clinical privileges, membership, contractual participation or employment by any medical organization (e.g., hospital medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), private payer (including those that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system) ever been denied, suspended, restricted, reduced, subject to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct or breach of contract, or is any such action pending?

� Yes � No

(E) Have your clinical privileges at any hospital or other health care organization (e.g., hospital medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO) private payer (including those that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system) ever been voluntarily or involuntarily suspended, restricted, limited, reduced or relinquished?

� Yes � No

(F) Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual participation or employment, or resigned from any medical organization (e.g., hospital medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), private payer (including those that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system) while under investigation for possible incompetence or improper professional conduct, or breach of contract, or in return for such an investigation not being conducted, or is any such action pending)?

� Yes � No

(G) Has your Medical Staff membership, contractual affiliation or employment with any hospital or other health care organization (e.g., hospital medical staff, medical group, independent practice association (IPA), health plan, health maintenance organization (HMO), preferred provider organization (PPO), private payer (including those that contract with public programs), medical society, professional association, medical school faculty position or other health delivery entity or system), ever been voluntarily withdrawn or terminated?

� Yes � No

(H) Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status in good standing in any internship, residency, fellowship, preceptorship, or other clinical education program?

� Yes � No

(I) Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, reduced, limited, subjected to probationary conditions, or not renewed, or is any such action pending?

� Yes � No

(J) Have you been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed (other than changing from eligible to certified)?

� Yes � No

(K) Have you ever been convicted of any crime (other than a minor traffic violation)? � Yes � No (L) Do you presently use any drugs illegally? � Yes � No (M) In the last five (5) years, have you had a history of chemical dependency or substance abuse that might adversely affect your ability to competently and safely perform the essential functions of a practitioner in your area of practice?

� Yes � No

(N) Have any judgments been entered against you, or settlements been agreed to by you, in professional liability cases, or are there any filed and served professional liability lawsuits/arbitrations against you pending? (if yes, please explain on a separate sheet of paper)

� Yes � No

(O) Has your professional liability insurance ever been terminated, no renewed, restricted, or modified (e.g., reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any professional liability carrier provided you with written notice of any intent to deny, cancel, not renew, or limit your professional liability insurance or its coverage of any procedures?

� Yes � No

DATE: ___________________________ SIGNATURE: _______________________________________________ Page 3 o:carol:Residentapplication19/20

LOS ANGELES COUNTY DEPARTMENT OF HEALTH SERVICES

VALLEYCARE OLIVE VIEW-UCLA MEDICAL CENTER AND HEALTH CENTERS

STATEMENT OF CONFIDENTIALITY OF PEER REVIEW/QUALITY IMPROVEMENT ACTIVITIES

OF THE PROFESSIONAL STAFF ASSOCIATION, COMMITTEES, DEPARTMENTS AND DIVISIONS

All information discussed, distributed, and prepared for peer review/quality improvement activities shall be deemed confidential, including but not limited to all material related to the performance of medical review, participation in a risk prevention program, or investigation/ discussion of any safety or quality of care issues. The Medical Director shall determine the persons or entities outside the respective committees or activities that are legally entitled to access this information. All minutes, files, and correspondence shall be kept secured in a designated area and distributed only as directed by the Medical Director. CONFIDENTIALITY AGREEMENT: As a member or a guest of peer review/quality improvement activities at ValleyCare Olive View-UCLA Medical Center, I agree to respect and maintain the confidentiality of all discussions, deliberations, records and other information generated in connection with these activities, and to make no voluntary disclosures of such information except to persons authorized to receive it by the Medical Director. I further understand that the organization is entitled to undertake action as is deemed appropriate to ensure that this confidentiality is maintained, including action necessitated by any breach or threatened breach of this agreement. Print full name ________________________________ Signature _____________________________________ Date __________________________ Page 4 o:carol:Residentapplication19/20

DISTRIBUTION OF HOUSE STAFF INFORMATION

Applicable County ITEMS/Position Titles for HOUSE STAFF: ITEM/Position Title 5408/Postgraduate Physician 1st Year* 5411/Postgraduate Physician 2nd-7th Year* 9439/Intern W/O Compensation 9440/Resident W/O Compensation The MEDICAL STAFF OFFICE receives the following: Original copy of House Staff Information Sheet Copy of Medical School Diploma Copy of E.C.F.M.G. Certificate (Foreign Graduated Physicians Only) Your DEPARTMENT FILES should retain the following: Original Copy of House Staff Information Sheet Copy of Medical School Diploma Copy of E.C.F.M.G. Certificate (Foreign Graduated Physicians Only) Page 5 o:carol:Residentapplication19/20

Olive View‐UCLA Medical Center 14445 Olive View Drive, Sylmar, CA 91342 

(747) 210‐3000 

 

 Employee Health 

Cottage G (747) 210‐3403 

Human Resources (747) 210‐3311  Credit Union 

Trailer O1 (818) 367‐1057 

Facilities (747) 210‐3325 

Conf Center 

Conference Center 

• Health Services LOS ANGELES COUN T Y

Los Angeles County Board of Supervisors

Hilda L. Solis Filst District

Mark Ridley-Thomas Second District

Sheila Kuehl Thrd District

Janice Hahn f ourlt> District

Kalhryn Barger Fifth District

Milchell H. Katz, M.D. Director

Hal F. Vee, Jr., M.D., Ph.D. Chief Medical Officer

Chrislina R. Ghaly, M.D. Chief Operations Officer

HUMAN RESOURCES OIVISION Ellzabelh M. Jacobi

Director 5555 Ferguson Drive. Suile 120-27

Commerce, CA 90022

Tel: (323) 869-7133 Fax: (323) 869-0374

www.dhs.lacounly.gov

To ensure access to high-quality, patient-centered, cost-effective health care to Los Angeles County residents through direct services at DHS 'acilities and through collaboration with community and university partners. > o

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DATE:

TO:

FROM:

NON-COUNTY ASSIGNMENT - BACKGROUND INVESTIGATION AND MEDICAL EXAMINATION

This is to advise you that your assignment with the Department of Health Services is contingent upon you passing a Live Scan criminal background investigation and clearance of a health screening.

Once these clearances are obtained, a start date for your assignment will be established.

Acknowledgment:

My signature below certifies that I was advised of and understand the above requirements_

Signature Date

GK

c: Personnel File

CRIMINAL HISTORY DISCLOSURE

FREQUENTLY ASKED QUESTIONS

Page 1 of 5 rev 10.02.17

1. Q: Why am I being asked to report my conviction history?

A: Los Angeles County asks about a candidate’s conviction history to decide whether it is compatible with the duties of the desired position and it helps the County determine each candidate’s suitability for the particular position being applied for.

2. Q: What is considered a conviction?

A: A conviction includes a plea, verdict or other finding of guilt by a court, including a military court, regardless of whether sentence is imposed by the court.

3. Q: If I have a past conviction, does that automatically prevent County employment?

A: In most circumstances, a conviction history does not automatically prevent County employment. Los Angeles County looks at conviction history on a case-by-case basis and evaluates several factors to determine whether the conviction is compatible with the duties and responsibilities of the desired position. However, please note that any candidate for County employment who has been convicted of workers’ compensation fraud is barred from employment with the County of Los Angeles (County Code Section 5.12.110).

4. Q: How does the County determine whether my conviction is compatible with the

position I applied for?

A: If the County makes you a contingent job offer, you will be asked to complete the Candidate Conviction History Questionnaire (CCHQ). As part of the background process, you will undergo Live Scan and your fingerprints will be submitted to the California Department of Justice (DOJ) and the Federal Bureau of Investigation (FBI) who will provide information about your conviction history.

Once the County receives information about your conviction history, it is reviewed to determine whether the information you provided is consistent with what was obtained from the DOJ and FBI. The County will also evaluate the information to determine whether there is a connection between any conviction and the job for which you are being considered. Additional factors considered by the County include, but are not limited to:

CRIMINAL HISTORY DISCLOSURE

FREQUENTLY ASKED QUESTIONS

Page 2 of 5 rev 10.02.17

� The nature and seriousness of the offense � The degree to which the conviction is related to the duties and responsibilities of

the job � Age when convicted � Length of time since the conviction � Whether the conviction was an isolated incident or part of a pattern � Evidence of rehabilitation � Level of risk to the public and/or County � Any other mitigating circumstance

5. Q: What is a Live Scan?

A: Live Scan is the digitally scanned fingerprinting process the County uses to obtain your

fingerprints. Live Scan allows digitally scanned fingerprints and related information to be submitted electronically to the DOJ and the FBI.

6. Q: What convictions must I disclose?

A: You must disclose all convictions by any criminal or military court, even if issued a

Certificate of Rehabilitation (but not yet pardoned) under California Penal Code Section 4852.16, except those listed in the CCHQ form and/or those protected from disclosure by a valid court order. Access to that form can be found at this link: http://file.lacounty.gov/SDSInter/dhr/247492_CCHQ.pdf

Please Note: Candidates for positions as peace officers or for positions with a criminal justice agency (as defined in Penal Code Section 13101) are subject to different disclosure requirements. If you are a candidate for one of those positions, please consult with the designated human resources office.

7. Q: Are there convictions that I do not need to disclose?

A: It is not necessary to disclose the following information related to conviction:

Expunged records

CRIMINAL HISTORY DISCLOSURE

FREQUENTLY ASKED QUESTIONS

Page 3 of 5 rev 10.02.17

It is not necessary to disclose any convictions that was expunged by a valid court order or that was judicially dismissed. An expungement of records occurs when a court orders the destruction/removal of arrest records or other court proceedings. A Penal Code, 1203.4 / 1203.4 (a) dismissal withdraws a previous verdict or plea of guilt or nolo contendere. The court then dismisses the charges against the person, and the person “shall thereafter be released from all penalties and disabilities resulting from the offense of which he or she was convicted.” Juvenile Offenses It is not necessary to disclose any conviction while a juvenile (under 18 years old), unless the job announcement identifies particular convictions that must be disclosed for that particular classification or position, regardless of age when convicted. Traffic Offenses It is not necessary to disclose a conviction for a traffic offense that was less than $390.

Miscellaneous Offenses It is not necessary to disclose any conviction for one of the following violations that is more than two years old:

A. Health & Safety Code Section 11357(b) or (c) (possession of marijuana), or any statutory predecessor to that section; B. Health & Safety Code Section 11360(c) (transportation of marijuana), or any statutory predecessor to that section; C. Health & Safety Code Section 11364 (possession of drug paraphernalia),

Section 11365 (presence in a place where a controlled substance is being used), and/or Section 11550 (use of a controlled substance) as they relate to marijuana prior to January 1, 1976, or any statutory predecessors to those sections.

8. Q: What if I don’t disclose a conviction that I am required to report?

A: Failure to include convictions on the CCHQ that you are required to disclose can be

considered falsification and may result in your disqualification from consideration for the position sought. If you are already appointed, failure to disclose convictions may

CRIMINAL HISTORY DISCLOSURE

FREQUENTLY ASKED QUESTIONS

Page 4 of 5 rev 10.02.17

lead to termination of your employment. Depending on the circumstances, it may also result in restrictions on future employment with the County.

9. Q: If I was disqualified from consideration, how do I determine what criminal history

information was used by the department? A: Per Penal Code 11105, departments “must expeditiously furnish a copy of the

information to the person to whom the information relates if the information is a basis for an adverse employment, licensing, or certification decision.” As such, the department will provide you with the disqualifying criminal history information.

If you determine such information to be inaccurate, you should contact the court of

jurisdiction and/or the DOJ to obtain your criminal history record.

10. Q: How can I obtain a copy of my criminal history record?

A: For State records, you may request your own Criminal Offender Record Information (CORI) from the court of jurisdiction, or you may contact the California Department of Justice (DOJ). To receive a copy of your CORI from DOJ, individuals must follow instructions shown at this link: https://oag.ca.gov/fingerprints/security.

Procedures for obtaining a copy of FBI criminal history records are set forth in Title 28, Code of Federal Regulations (CFR), Section 16.30 through 16.33 or go to the FBI website at http://www.fbi.gov/about-us/cjis/background-checks.

11. Q: How can I change, correct, or update my criminal history records?

A: If you feel the information contained within your DOJ criminal history record is

incorrect, you may submit a formal challenge to the DOJ only after you have received a copy of your record from the DOJ, pursuant to California Penal Code Sections 11120-11127. Form BCIA 8706 "Claim of Alleged Inaccuracy or Incompleteness" will be mailed to you along with your record. Submit form BCIA 8706 and any supporting documentation to the DOJ at the address provided on the form. The challenge will be reviewed and a written response will be provided, along with an amended copy of your criminal history record if appropriate.

CRIMINAL HISTORY DISCLOSURE

FREQUENTLY ASKED QUESTIONS

Page 5 of 5 rev 10.02.17

Procedures for obtaining a change, correction, or updating of an FBI criminal history record are set forth at Title 28, Code of Federal Regulations (CFR), Section 16.34.

12. Q: What if I disagree with the County’s decision to disqualify me due to my conviction(s)?

A: If you believe that an error has been made in determining your eligibility, you may file

an appeal with the Department of Human Resources. The appeal must be in writing and provide specific facts and information, which demonstrate where the error occurred. Any appeal that fails to contain such information will be denied as insufficient. The appeal must be received by the Appeals Program within ten (10) business days from the postmark date on the envelope in which this notice was mailed, by using this web address: https://eappeals.lacounty.gov. For technical support related to online appeal submissions go to http://apps.hr.lacounty.gov/eAppeal/.

�

�

TO:� � Workforce�Members�(County/Non�County)�

FROM:� � Human�Resources�Manager�

SUBJECT:� Photo�Identification�(ID)�Badge�

Please�read�the�following�procedures�carefully,�as�specified�in�DHS�Policy�940:�

1. Your�ID�badge�must�be�prominently�displayed�at�all�times�while�on�duty�on�County�premises.��Personnel�failing�to�display�their�ID�badges�shall�identify�themselves�upon�request�to�any�employee.�

2. It� is� your� responsibility� to� report� a� lost/stolen� ID� badge� within� five� (5)� business� days� to� the� law� enforcement�agency�having�jurisdiction�where�the�loss/theft�occurred.��You�must�sign�an�affidavit�attesting�to�the�fact�that�the�ID� badge� was� lost/stolen,� and� provide� Human� Resources� with� a� copy� of� the� police� report� along� with� the�replacement�cost�of�the�ID�badge.��Copies�of�all�documents�will�be�filed�in�your�official�personnel�file.�

3. You� are� required� to� pay� for� the� replacement� of� your� ID� badge� if� it� is� not� returned� or� is� lost,� damaged,� or�destroyed�due�to�personal�negligence.��Replacement�fees�for�ID�badge�are�as�follows:�

First�Identification�badge�replacement:� � $25.00�Second�identification�badge�replacement:� $50.00�Third�identification�badge�replacement:� � $100.00��

4. Your� ID�badge�must�be�returned�to�your�supervisor�upon�termination�of�employment/assignment.� � If� it� is�not�returned� because� it� is� lost/stolen,� you� must� submit� a� copy� of� the� police� report� and� affidavit.� � If� you� do� not�submit�either�of�the�above,�the�payment�of�your�accrued�benefits�may�be�withheld�up�to�three�(3)�months.�

If�you�state�that�you�have�the�ID�badge�but�refuse�to�return�it,�the�payment�of�your�accrued�benefits�will�not�be�issued�until�such�time�as�the�ID�badge�is�returned.�

5. Unauthorized� use� of� your� ID� badge� will� be� cause� for� severe� disciplinary� action� which� could� include� discharge�from�County�service.�

I�have�read�the�above�procedures�and�agree�to�comply�with�them.�

Print�name:� � � Title:� �

Signature:� � � Emp#�(if�applicable):� �

Division/Agency/School:� �

� Photographer’s�initials:� � Date:� �

Orig:�Employee�Personnel�File�

�

HOA.798791.1

EMPLOYEE ACKNOWLEDGEMENT AND RECEIPT OF

COUNTY POLICY OF EQUITY

I, ________________________________, _______________________________ Employee Name Payroll Title

acknowledge that I am expected to read, understand and adhere to the County Policy of Equity and have received a copy.

DATE: ______________________________________________________

DEPT: ______________________________________________________

EMPLOYEE SIGNATURE: __________________________________________

EMPLOYEE NUMBER: __________________________________________

Distribution:

1.) Original to Official Personnel File 2.) Record in Countywide Learning Management System (LMS)

NEW PROVIDER ORIENTATION ATTESTATION MANDATORY TRAINING

REV06212018

Background: The County of Los Angeles, Department of Health Services (DHS), is contracted with Health Plans to operate as a Participating Provider Group (PPG) and to provide Hospital services. Through this collaboration, DHS and the Health Plans provide and/or arrange for healthcare services for DHS assigned members. Pursuant to the agreements, DHS providers are required to review and understand the following information. In addition to the DHS New Orientation packet, Health Plan’s websites provide additional resources and opportunities for provider education. Information related to DHS’ contracts with Health Plan’s is available on DHS’ intranet in the “Clinical Resources” section at http://myladhs.lacounty.gov/SitePages/Home.aspx. For more information about the Health Plan’s programs, please visit their websites as follows: L.A. Care: http://www.lacare.org/providers Health Net: https://www.healthnet.com/portal/provider/home.ndo Information available includes but is not limited to: • DHS Provider Agreement with Managed Care Health Plans • Health Plan’s Provider Manual and Guidelines • Health Plan’s Member Handbooks • Health Plan’s Operations Manual • Interpreter Services • Provider Update • I.C.E. Better Communication, Better Care: Provider Tools to Care for Diverse Populations • Member’s Rights and Responsibilities • Quality Improvement Programs • Preventive Health Guidelines • Access Standards

OPTIONAL TRAINING: Screening, Brief Intervention, and Referral to Treatment (SBIRT) New DHS providers will be automatically enrolled into the Screening, Brief Intervention, and Referral to Treatment (SBIRT) training onto the Learning Net. This training is highly encouraged if you work with patients who are at risk for substance use disorders; however, it is not mandatory. Upon completion of this training, you will receive 4.0 CME units. The training is in accordance with the DHCS All Plan Letter (APL) 17-016 Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care. This APL explains the obligations of Medi-Cal managed care health plans (MCPs) to provide Alcohol Misuse: Screening and Behavioral Counseling Interventions in Primary Care. The SBIRT training will fulfill the requirements of this APL. A copy of the APL and MCS policy is included in the DHS intranet in the Clinical Resources section at http://myladhs.lacounty.gov/SitePages/Home.aspx . I acknowledge that I have read, reviewed and understand the above information. If I have questions or concerns, I will contact my Director for clarification. Provider Name (First Name, Middle Initial, Last Name): ___________________________________________ _____________________________________________ ____________________________________ Signature Employee/Contract Number: Date: _________________________________