Get the free MEDI-CAL CERTIFICATION AND TRANSMITTAL DHCS 1735 (Rev. 09/2014). MEDI-CAL CERTIFICAT...

State of California Health and Human Services AgencyDepartment of Health Care ServicesMEDICAL CERTIFICATION AND TRANSMITTAL PART COUNTY INFORMATIONCOUNTY SUBMITTING FORM: PART PROVIDER #: NPI#: Medical

How to fill out medi-cal certification and transmittal

How to fill out medi-cal certification and transmittal

1. To fill out the Medi-Cal certification and transmittal form, follow these steps:
2. Obtain a copy of the form: You can find the Medi-Cal certification and transmittal form on the official website of Medi-Cal or request a physical copy from your local Medi-Cal office.
3. Fill out basic information: Enter the date, your name, address, contact details, and any other requested personal information at the top of the form.
4. Provide patient information: Fill in the patient's full name, date of birth, gender, Medi-Cal identification number (if available), and other relevant details.
5. Complete the certification: Answer the certification questions accurately and honestly to ensure compliance with Medi-Cal regulations.
6. Attach supporting documents: If required, provide any necessary supporting documents, such as medical records, bills, or other paperwork related to the patient's eligibility for Medi-Cal.
7. Sign and date the form: At the bottom of the form, sign and date it to attest to the accuracy of the information provided.
8. Submit the form: Send the completed form and any attachments to the designated Medi-Cal office either by mail or electronically, depending on the preferred submission method.
9. Keep copies for your records: Make copies of the filled-out form, attachments, and any other relevant documents for your personal records.
10. It's important to double-check the accuracy and completeness of the form before submission to avoid delays or complications in processing.

Who needs medi-cal certification and transmittal?

1. Medi-Cal certification and transmittal may be required by individuals or organizations that need to request reimbursement for healthcare services provided to Medi-Cal beneficiaries.
2. This includes healthcare providers, medical facilities, clinics, or any other entity that participates in the Medi-Cal program and needs to bill for services rendered.
3. Additionally, individuals applying for Medi-Cal benefits may also need to fill out a Medi-Cal certification and transmittal form as part of the application process.

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What is medi-cal certification and transmittal?

Medi-Cal certification and transmittal is a formal process used to verify and submit information regarding medical services provided under the Medi-Cal program, ensuring compliance with state requirements.

Who is required to file medi-cal certification and transmittal?

Providers who deliver medical services to Medi-Cal beneficiaries are required to file the medi-cal certification and transmittal.

How to fill out medi-cal certification and transmittal?

To fill out the medi-cal certification and transmittal, providers must gather necessary patient information, service details, and reimbursement data, and then complete the standardized forms as per the instructions provided by the state.

What is the purpose of medi-cal certification and transmittal?

The purpose of medi-cal certification and transmittal is to ensure that healthcare providers receive appropriate reimbursement for services rendered to Medi-Cal recipients and to maintain compliance with state and federal regulations.

What information must be reported on medi-cal certification and transmittal?

The information that must be reported includes provider details, patient information, the nature of services rendered, dates of service, and any applicable billing codes.