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                           *** *** ONLY ACCEPTING RESUBMISSIONS *** ***           


Before you begin, make sure you have read the detailed instructions here and collected the information you need to successfully complete this registration.

*** *** THE REGISTRATION PROCESS IS INTENDED FOR EMPLOYERS TO FILL OUT AND REQUIRES EMPLOYER-SPECIFIC INFORMATION*** ***
This Registration is NOT intended for Employees to complete for themselves. Please refer to the guidance documents and FAQs or consult with your employer.

Disclosure of Personal Information. In order to validate identity and qualification for participation in the Clinic Workforce Stabilization Retention Payment (CWSRP), it may be necessary to share information you provide with authorized state/federal agencies or third party vendors. While it is your choice to complete the registration and application process, failure to complete the entire process will result in the inability to determine eligibility and make corresponding retention payments.

Privacy Notice, Civ. Code section 1798.17: The personal information collected on and with this form is confidential, subject to the Department of Health Care Services (DHCS) Notice of Privacy Practices that can be found here: https://www.dhcs.ca.gov/formsandpubs/laws/priv/Documents/Notice-of-Privacy-Practices-English.pdf. DHCS needs the information to administer the CWSRP. DHCS will not use or share the information for other purposes except with your permission or as permitted by law.  You must provide all information requested on this form. If you do not provide all information requested, we may not be able to decide if you qualify for payment. In most cases, the individual(s) to whom this information pertains has the right to access it.  DHCS is authorized to collect this information pursuant to Labor Code section 1492.  This privacy notice provided here is required by California Civil Code section 1798.17.

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* 1. Please check the box to accept the above Disclosure and Privacy Statements before proceeding.

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