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Attachment B
[Primary Care Providers Only]
MCP Name: Molina Healthcare of Ohio, Inc.
Signature:
Printed Name: AMI Cole
Title:
VP, Plan Operations
Date:
LastFirstMI Degree SpecialtySubcontractor/PVR
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How to fill out attachment b non-primary care
How to fill out attachment b non-primary care
01
Obtain a copy of attachment b non-primary care form from the appropriate source.
02
Fill out the patient's information accurately including name, date of birth, and contact information.
03
Provide details about the non-primary care provider including name, specialty, and contact information.
04
Describe the reason for the non-primary care visit and any necessary medical history.
05
Sign and date the form before submitting it to the relevant party.
Who needs attachment b non-primary care?
01
Patients who have received non-primary care services from a healthcare provider other than their primary care physician may need to fill out attachment b non-primary care form.
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What is attachment b non-primary care?
Attachment B non-primary care is a form used to report non-primary care services provided by a healthcare provider.
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?
To fill out attachment B non-primary care, healthcare providers need to provide detailed information about the non-primary care services provided.
What is the purpose of attachment b non-primary care?
The purpose of attachment B non-primary care is to ensure accurate reporting and billing for non-primary care services.
What information must be reported on attachment b non-primary care?
On attachment B non-primary care, healthcare providers must report details such as the type of non-primary care service provided, dates of service, and charges.
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