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This copy of the Form is for reference only STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCYDEPARTMENT OF HEALTH CARE SERVICESMULTIPLE BILLING OVERRIDE CERTIFICATIONPROVIDER NAME: CLIENT NAME:
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Start by opening the document or form that requires an explanation of changes.
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Read through the document to understand the changes that have been made.
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Explanation of changes without is a document that provides details on modifications made to a previous submission without filing an official amendment.
Any individual or entity that has made changes to a previous submission without formally amending the document is required to file an explanation of changes without.
To fill out an explanation of changes without, include a detailed description of the changes made, the reason for not filing an official amendment, and any supporting documentation.
The purpose of explanation of changes without is to provide transparency regarding modifications made to a previous submission without filing an amendment.
The information that must be reported on an explanation of changes without includes details on the changes made, reasons for not filing an official amendment, and any supporting documentation.
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