PHC has released a new form, Form Cdph 318 "Notice of Privacy Practices". This form must be given to all individuals who receive services from PHC. The form describes how PHC may use and disclose protected health information about the individual. It also describes the individual's rights with respect to their protected health information. By law, PHC is required to provide this form to individuals annually or when any changes are made to the privacy practices described in it. Be sure to review your copy of Form Cdph 318 and update your policies and procedures as needed. If you have any questions, please contact the Compliance Department at compliance@PHConline.com or 855-746-4676. Thank you!
| Question | Answer |
|---|---|
| Form Name | Form Cdph 318 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | cdph318 cnahhacht form |
State of California - Health and Human Services Agency |
California Department of Public Health |
CNA/HHA/CHT REPORT OF MISCONDUCT
To: California Department of Public Health (CDPH)
Licensing and Certification Program (L&C)
Investigation Section, MS 3303
P.O. Box 997416
Sacramento, CA
(916)
FAX: (916)
From reporting party:
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Telephone:
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Please provide a brief description and date of incident. Use reverse of more space is needed.
If available, please provide the following information:
●Copies of any investigation reports initiated by the facility, district office, law enforcement agency, or any other agency.
●Copies of any signed witness/resident statements which pertain to this incident.
●Copies of any previous incidents and employee disciplinary action.
●Names and addresses of any law enforcement agency or other agency to whom this was reported. (Please list all referrals/reports on the reverse side of this form.)
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CDPH 318 (08/11) This form is available on our website at: www.cdph.ca.gov
Reported to:
LICENSING AND CERTIFICATION DISTRICT OFFICE |
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Complaint investigation conducted?
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LAW ENFORCEMENT AGENCY |
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Complaint investigation conducted?
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Did it result in an arrest:
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Report number
OMBUDSMAN |
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Complaint investigation conducted?
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Complaint description (continued).
INFORMATION COLLECTION AND ACCESS: PRIVACY STATEMENT
*Social Security Number Disclosure: Pursuant to Section 666(a)(13) of Title 42 of the United States Code and California Family Code, Section 17520, subdivision (d), the California Department of Public Health (CDPH), is required to collect social security numbers from all applicants for nursing assistant certificates, home health aide certificates, hemodialysis technician certificates or nursing home administrator licenses. Disclosure of your social security number is mandatory for purposes of establishing, modifying, or enforcing child support orders upon request by the Health Integrity and Protection Data Bank as required by 45 CFR §61.1 et seq . Failure to provide your social security number will result in the return of your application. Your social security number will be used by CDPH for internal identification, and may be used to verify information on your application, to verify certification with another state's certification authority, for examination identification, for identification purposes in national disciplinary databases or as the basis of a disciplinary action against you.
Note: Reports made to the Investigation Section will be coordinated with other agencies.
CDPH 318 (08/11) This form is available on our website at: www.cdph.ca.gov