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MEDICAL DENTAL CHOICE Forms this form to join or change a dental plan or return to Regular Medical. If you need help filling out this form, call 18004304263. Mail Completed form to: California Department
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How to fill out medi-cal dental choice form
How to fill out medi-cal dental choice form
01
Obtain the Medi-Cal Dental Choice form from your Medi-Cal dental provider or download it from the official website.
02
Fill in your personal information, including your full name, date of birth, and contact details.
03
Provide your Medi-Cal identification number and the name of your dental provider.
04
Indicate the type of service you are requesting by checking the appropriate boxes.
05
If you are requesting a specific treatment or procedure, provide a brief description.
06
If you have any additional information or special needs, you can include them in the designated space.
07
Review the form for accuracy and completeness.
08
Sign and date the form to certify that the information provided is true and correct.
09
Submit the completed form to your Medi-Cal dental provider or the designated office.
10
Keep a copy of the form for your records.
Who needs medi-cal dental choice form?
01
Anyone who is eligible for Medi-Cal and requires dental services can use the Medi-Cal Dental Choice form. This form is used to request specific dental treatments or procedures under the Medi-Cal program.
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What is medi-cal dental choice form?
The medi-cal dental choice form is a form that allows Medi-Cal beneficiaries to select a dental plan for their dental services.
Who is required to file medi-cal dental choice form?
All Medi-Cal beneficiaries who are eligible for dental services are required to file the medi-cal dental choice form.
How to fill out medi-cal dental choice form?
The medi-cal dental choice form can be filled out online, through the mail, or in person at a local Medi-Cal office.
What is the purpose of medi-cal dental choice form?
The purpose of the medi-cal dental choice form is to allow Medi-Cal beneficiaries to choose a dental plan that best suits their needs and preferences.
What information must be reported on medi-cal dental choice form?
The medi-cal dental choice form requires basic information such as name, address, Medi-Cal ID number, and chosen dental plan.
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