Get Form 7700

The Form 7700 is crucial for Drug Medi-Cal Providers to certify multiple billing for a single client on the same service date. This guide will provide you with clear and step-by-step instructions to successfully fill out this form online.

Follow the steps to complete the Form 7700 online.

1. Click ‘Get Form’ button to access the form and open it in your editor.
2. Enter the provider name in the designated field to identify your organization.
3. Input the client’s name as it appears on the record for the claim.
4. Fill in the month and year of the services provided in the appropriate format.
5. Provide the client identification number (CIN) for accurate tracking.
6. Input the service facility’s National Provider Identifier (NPI) code.
7. If the provider is a sole proprietor, enter the complete ZIP code plus four digits.
8. Input the specific date when the service was administered.
9. Enter the number of service units being billed for that date.
10. Provide the procedure code modifier found in the ADP Companion Guide for accurate billing.
11. Choose an override reason from the provided options and ensure your client record supports this reason.
12. In the signature block, only authorized representatives should sign the form.
13. Enter the title of the person signing the form to identify their role.
14. Fill in the date when the authorized representative signed the form.
15. Once you have completed all fields, save your changes, and then choose to download, print, or share the form as needed.

Complete your Form 7700 online today to streamline your billing process.