Get Form: Medi-cal Point Of Service (pos) Network/internet Agreement ... - Dhcs Ca

Filling out the Medi-Cal Point Of Service (POS) Network/Internet Agreement is essential for all providers and authorized representatives intending to use the Medi-Cal website and network. This guide will provide you with comprehensive, step-by-step instructions on how to accurately complete the form online.

Follow the steps to successfully complete the Medi-Cal POS Network/Internet Agreement.

1. Click the ‘Get Form’ button to access the form and upload it to your preferred form editor.
2. Provide the required details for enrolled Medi-Cal providers in Section I. This includes your Provider Name, Provider Number/NPI, Owner Number (if applicable), and Tax ID. Make sure to double-check these entries.
3. If you are using non-Medi-Cal software or hardware, enter the Vendor/Developer Company Name and CMC Submitter Number (if applicable). Additionally, provide a Contact Person and their Phone Number.
4. For non-provider users representing a provider, fill in the authorized provider representative’s name and ensure you attach a list of all provider numbers/NPIs and respective Tax Identification Numbers, if necessary.
5. If you wish to delete access for a representative, specify their name in the appropriate section and attach a list of all provider numbers/NPIs related to the deletion.
6. In Section II, denote the transactions you agree to limit your usage of the Medi-Cal website and POS Network to. This could include eligibility verification, claims submission, and other listed transactions.
7. Review and agree to the security requirements mentioned in Section V. Ensure that your systems comply with all specified security protocols.
8. Read Section VI to understand and acknowledge the fees associated with using the Medi-Cal POS Network, especially regarding transaction fees for pharmacy claims.
9. Ensure you complete any required testing for your system as expressed in Section VII before activating it for transactions.
10. Complete the signature section at the end of the form which includes your printed name, signature, title, and date. Ensure all fields are filled accurately.
11. Once completed, save your changes, then download or print the form. If applicable, send it via mail to the designated address provided at the end of the form.

Start filling out the Medi-Cal Point Of Service Network/Internet Agreement online today to ensure you can effectively use Medi-Cal services.