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State of California Health and Human Services Agency Department of Health Care Services Substance Use Disorder Compliance Division 30-MONTH DUI PROGRAM QUARTERLY LICENSING AND PARTICIPANT ENROLLMENT
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How to fill out dhcs form 5074 dui
How to fill out dhcs form 5074 dui:
01
Start by gathering all the necessary information. You will need details about the DUI offense, such as the date, time, location, and charges.
02
Fill in your personal information accurately. Provide your full name, address, date of birth, and contact information.
03
Complete the section related to the DUI offense. Include information about the arresting officer, police agency, court jurisdiction, and any subsequent legal proceedings.
04
Provide information about any addiction treatment programs you have participated in or are currently enrolled in. Include details about the program name, dates attended, and the reason for your participation.
05
If you have any prior DUI convictions, indicate them in the relevant section. Include information about the date, location, and charges for each offense.
06
Sign and date the form to certify that all the information provided is true and accurate to the best of your knowledge.
Who needs dhcs form 5074 dui:
01
Individuals who have been arrested for a DUI offense and are required to provide information about their addiction treatment history.
02
Anyone who is currently participating in or has participated in an addiction treatment program related to a DUI offense.
03
Individuals who have prior DUI convictions and are required to disclose this information as part of their legal proceedings or for licensing purposes.
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What is dhcs form 5074 dui?
DHCS form 5074 DUI is a form used by the California Department of Health Care Services (DHCS) to gather information about driving under the influence (DUI) incidents.
Who is required to file dhcs form 5074 dui?
Individuals who have been convicted of a DUI in California are required to file DHCS form 5074 DUI.
How to fill out dhcs form 5074 dui?
DHCS form 5074 DUI can be filled out by providing personal information, details of the DUI conviction, and any other requested information accurately.
What is the purpose of dhcs form 5074 dui?
The purpose of DHCS form 5074 DUI is to collect information on DUI convictions to assess potential impacts on healthcare licensure and eligibility.
What information must be reported on dhcs form 5074 dui?
Information such as personal details, DUI conviction details, court information, and treatment program completion may need to be reported on DHCS form 5074 DUI.
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