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Request Support
About
Our Story
Vision
Team
How we help
Ideas for Support
Resources
Traditional Health
Request Support
Request Support
About Us
Our Story
Vision
Team
How We Help
Ideas for Support
Resources
Traditional Health
Request Training and Technical Assistance
After filling out this form, our staff will follow up with more information.
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Is this request related to the traditional health care practices Medi-Cal benefit (Approved via the Medi-Cal Section 1115 Waiver)?
*
Yes
No or Unsure
Name
*
First
Last
Email
*
Phone
*
Preferred method of communication
Email
Phone
Agency/Organization/Individual
*
Agency/Organization/Individual *
Agency
Organization
Individual
Name of Organization
*
Title
*
Type of request
*
Type of request *
Tribe
Organization
Individual
Other
Request Type - other
*
Please specify which type of substance is being addressed in this request
*
Please specify which type of substance is being addressed in this request *
Opioids
Other
Substance Type - other
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Physical address
*
County location
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Organization website (if applicable) - HTTP validate
Which of the following best describes your organization?
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Tribal health program
Urban Indian health program
County health services agency
Managed care organization
Non-profit organization
Other
thcp_org_desc_other
Primary county(s) served
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Alameda
Alpine
Amador
Butte
Calaveras
Colusa
Contra Costa
Del Norte
El Dorado
Fresno
Glenn
Humboldt
Imperial
Inyo
Kern
Kings
Lake
Lassen
Los Angeles
Madera
Marin
Mariposa
Mendocino
Merced
Modoc
Mono
Monterey
Napa
Nevada
Orange
Placer
Plumas
Riverside
Sacramento
San Mateo
Santa Barbara
San Benito
San Bernardino
San Diego
San Francisco
San Joaquin
San Luis Obispo
Santa Clara
Shasta
Sierra
Siskiyou
Solano
Sonoma
Stanislaus
Sutter
Tehama
Trinity
Tulare
Tuolumne
Ventura
Yolo
Yuba
Indicate the Type(s) of Technical Assistance Being Requested
TA Types
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Virtual or remote training and technical assistance
Naloxone Distribution Program (NDP) training and technical assistance
Other
TA Type - other
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TA Types - THCP
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Orientation to traditional health care practices
Support for completing opt-in package or policies and procedures development
Evidence-Based Practices (EBP) support
Practitioner qualifications
IHCP Medi-Cal and DMC-ODS certification/enrollment
IHCP-County Coordination
Service documentation requirements
Claiming and payment
Oversight and Monitoring
DMC-ODS County Requirements
Other or not sure (please include below)
TA Type - other - THCP
*
Comment or Message
*
Send