CA DHCS MC 604 IPS 2014-2025 free printable template
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State of California Health and Human Services Agency Department of Health Care Services ADDITIONAL INCOME AND PROPERTY INFORMATION NEEDED FOR MEDICAL We are still evaluating your Medical eligibility
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How to fill out CA DHCS MC 604 IPS
How to fill out CA DHCS MC 604 IPS
01
Obtain the CA DHCS MC 604 IPS form from the Department of Health Care Services website or your local office.
02
Fill in the applicant's personal information at the top, including name, address, and contact details.
03
Indicate the type of services being requested in the designated section.
04
Provide detailed descriptions of the services needed and any relevant medical history.
05
Sign and date the form, ensuring that any necessary witnesses are present if required.
06
Submit the completed form to the appropriate local DHCS office or through the specified submission method.
Who needs CA DHCS MC 604 IPS?
01
Individuals seeking Medi-Cal services in California.
02
Caregivers or representatives submitting on behalf of a Medi-Cal applicant.
03
Providers or healthcare professionals assisting clients with Medi-Cal applications.
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What is CA DHCS MC 604 IPS?
CA DHCS MC 604 IPS is a form used in California's Department of Health Care Services to report institutional patient status for Medi-Cal beneficiaries.
Who is required to file CA DHCS MC 604 IPS?
Providers of residential or institutional care for Medi-Cal beneficiaries are required to file CA DHCS MC 604 IPS.
How to fill out CA DHCS MC 604 IPS?
To fill out CA DHCS MC 604 IPS, providers must accurately enter patient information, including personal details, admission date, and discharge status, as instructed on the form.
What is the purpose of CA DHCS MC 604 IPS?
The purpose of CA DHCS MC 604 IPS is to ensure accurate reporting of patient status and facilitate the appropriate billing and reimbursement within the Medi-Cal system.
What information must be reported on CA DHCS MC 604 IPS?
The information that must be reported on CA DHCS MC 604 IPS includes the patient’s name, date of birth, Medi-Cal identification number, facility details, admission and discharge dates, and any relevant medical information.
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