Get Caloptima Direct Administrative

Filling out the CalOptima Direct Administrative form is crucial for enrolling in electronic funds transfer (EFT). This guide provides a step-by-step approach to ensure you complete the form accurately and efficiently.

Follow the steps to complete the CalOptima Direct Administrative form correctly

1. Press the ‘Get Form’ button to acquire the form and access it in the online editor.
2. Review the instructions carefully. Ensure all requested information is provided. Signatures, if required, should be in blue ink—avoid using signature stamps. Note that any document containing banking information must not be copied, pasted, or saved within the online system.
3. Complete the action requested section of the form by selecting 'New,' 'Change,' or 'Term' to indicate your request type. Fill in the provider name and ensure your legal business name is listed if applicable. Additionally, include your CalOptima Provider ID, National Provider Identifier (NPI), and Federal Tax Identification Number (W-9 must be attached).
4. Provide the complete service address, along with relevant office contact details such as name, email address, phone number, and fax number. If you are changing or terminating an account, please explain the reason in the designated section.
5. Fill in your bank information. Include the bank name, complete address, and confirm your routing number with your financial institution. Ensure the routing number is a 9-digit number.
6. Indicate the type of account, ensuring only one box is checked—either checking or savings. Write your account number exactly as it should appear, ensuring accuracy.
7. The form must be signed by the provider, who is either the owner or a corporate officer. Print your name, sign, and date it in the specified area. Don’t forget to have your signature notarized.
8. Mail the completed form and any required verification documentation to the address provided at the top of the form. You may contact the Provider Enrollment Unit if you have questions during the process.

Complete your enrollment in the CalOptima Direct Administrative form online today.