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CA DHCS Form MC 330 2003 free printable template

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State of California Health and Human Services Agency Department of Health Services NEWBORN REFERRAL (NOT AN APPLICATION FOR MEDICAL) (PLEASE USE INK AND PRESS FIRMLY.) The Newborn Referral Form is
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CA DHCS Form MC 330 Form Versions

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CA DHCS Form MC 330 2015
4.9 Satisfied (43 Votes)
CA DHCS Form MC 330 2003
4.4 Satisfied (69 Votes)

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Begin by downloading the CA DHCS Form MC 330 from the official website.
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Read the instructions carefully to understand the purpose of the form.
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Fill in the applicant's personal information, including name, address, phone number, and date of birth.
04
Provide details about the Medicare number, if applicable.
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Ensure that all required signatures are provided where indicated.
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Review the completed form for accuracy and completeness.
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Submit the form by the specified means (mail, fax, or online submission) as instructed.

Who needs CA DHCS Form MC 330?

01
Individuals applying for Medi-Cal benefits or those needing to report changes to their Medi-Cal status.
02
Beneficiaries of other health programs who are required to update or confirm their information with CA DHCS.
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CA DHCS Form MC 330 is a form used by the California Department of Health Care Services to collect information about the services provided to beneficiaries of Medi-Cal programs.
Providers who deliver Medi-Cal services and wish to receive reimbursement for those services are required to file CA DHCS Form MC 330.
To fill out CA DHCS Form MC 330, providers must provide accurate information about patient demographics, service dates, types of services provided, and the corresponding billing codes.
The purpose of CA DHCS Form MC 330 is to ensure accurate reporting of services provided to Medi-Cal beneficiaries for the purpose of reimbursement and maintaining compliance with state regulations.
Information that must be reported on CA DHCS Form MC 330 includes patient identification, dates of service, type of service, service codes, provider details, and any other relevant billing information.
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