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Appendix A AFFILIATED PROVIDER FORM for Providers who are provided with an HCAI UserID for accessing the HCAI System in electronic format on behalf of an HCAIenrolled facility Health Claims for Auto

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What is dependent-provider-hcai-enrolled-facility-form-cmac?

The dependent-provider-hcai-enrolled-facility-form-cmac is a form used in the healthcare system to provide information about dependent providers enrolled in the HCAI (Healthcare Access and Information) for facilities participating in the CMAC (California Medical Assistance Commission) program.

Who is required to file dependent-provider-hcai-enrolled-facility-form-cmac?

Healthcare facilities that employ or contract with dependent providers who are enrolled in the HCAI system are required to file the dependent-provider-hcai-enrolled-facility-form-cmac.

How to fill out dependent-provider-hcai-enrolled-facility-form-cmac?

To fill out the dependent-provider-hcai-enrolled-facility-form-cmac, you need to provide accurate information regarding the dependent provider, including their name, qualifications, enrollment details, and any relevant facility information.

What is the purpose of dependent-provider-hcai-enrolled-facility-form-cmac?

The purpose of the dependent-provider-hcai-enrolled-facility-form-cmac is to ensure that all dependent providers working in HCAI-enrolled facilities are properly documented and compliant for participation in the CMAC program.

What information must be reported on dependent-provider-hcai-enrolled-facility-form-cmac?

The form must report information such as the dependent provider's personal details, their HCAI enrollment number, the type of services they provide, and the facility's licensing information.

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