Get the free Attachment B NON-Primary Care Providers Only

MCP Name: Molina Healthcare of Ohio, Inc. Signature: Signature: Printed Name: Dan Kodak Printed Name: Title: Director, Provider Contracts Title:

How to fill out attachment b non-primary care

How to fill out attachment b non-primary care:

1. Start by filling out the header information, including your name, contact information, and the date.
2. In section A, provide the name of the patient for whom the non-primary care services are being requested. Include their date of birth and any other pertinent identifying information.
3. Section B requires you to specify the primary care physician (PCP) and their contact information. If the patient does not have a PCP, indicate this as well.
4. Proceed to section C, where you will indicate the reason for requesting non-primary care services. Provide a detailed explanation, including any relevant medical conditions that require such services.
5. In section D, specify the duration for which non-primary care services are requested. Include the start and end dates, if applicable.
6. Section E asks for any medical records or supporting documentation related to the request. Indicate whether these records are attached with the form or will be provided separately.
7. Make sure to sign and date the form in section F to validate your request.
8. Finally, submit the completed attachment b non-primary care form to the appropriate party or department for processing.

Who needs attachment b non-primary care:

1. Patients who require specialized medical services that fall outside the scope of primary care may need attachment b non-primary care.
2. Individuals with complex medical conditions or chronic illnesses that necessitate the involvement of specialists or other healthcare providers may require this attachment.
3. Patients seeking coverage or reimbursement for non-primary care services from insurance providers or government agencies may be required to fill out attachment b as part of the application process.

For pdfFiller’s FAQs

What is attachment b non-primary care?

Attachment B non-primary care is a form that lists non-primary care services provided by healthcare providers.

Who is required to file attachment b non-primary care?

Healthcare providers who offer non-primary care services are required to file attachment B non-primary care.

How to fill out attachment b non-primary care?

Attachment B non-primary care should be filled out by listing each non-primary care service provided and the corresponding information for each service.

What is the purpose of attachment b non-primary care?

The purpose of attachment B non-primary care is to provide detailed information about non-primary care services offered by healthcare providers.

What information must be reported on attachment b non-primary care?

Information such as the type of non-primary care service provided, the date of service, the healthcare provider's information, and any relevant billing codes must be reported on attachment B non-primary care.

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