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Print Form IDENTICAL CALIFORNIA MEDICAL DENTAL PROGRAM P.O. BOX 15609 SACRAMENTO, CALIFORNIA 95852-0609 Phone 800-423-0507 Web www.denti-cal.ca.gov Reset Form (R 1/14) ELECTRONIC FUNDS TRANSFER (EFT)
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What is print form denti-cal california?
Print form denti-cal california is a form used for submitting claims for dental services to the Denti-Cal program in California.
Who is required to file print form denti-cal california?
Dentists and dental providers who are enrolled in the Denti-Cal program in California are required to file print form denti-cal california for reimbursement of dental services.
How to fill out print form denti-cal california?
Print form denti-cal california should be filled out with the patient's information, details of the dental services provided, and the dentist's information. It should then be submitted to the Denti-Cal program for reimbursement.
What is the purpose of print form denti-cal california?
The purpose of print form denti-cal california is to request reimbursement for dental services provided to patients under the Denti-Cal program in California.
What information must be reported on print form denti-cal california?
Print form denti-cal california must include the patient's name, date of birth, Denti-Cal ID number, the date of service, description of services provided, and the dentist's information.
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