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Signed by Patient Date Or Signed by Personal Representative On Behalf of DHCS 6247 11/07 Page 1 of 2 IDENTIFYING INFORMATION COPY OF IDENTIFICATION ATTACHED TYPE CA DRIVER S LICENSE CA DMV IDENTIFICATION CARD BIRTH CERTIFICATE BENEFITS IDENTIFICATION CARD MANAGED CARE CARD STATE OR FEDERAL EMPLOYEE ID CARD NUMBER IF NO IDENTIFICATION IS ATTACHED YOUR SIGNATURE MUST BE NOTARIZED.

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Haven't received your member medical ID card yet? Or do you need to go to a doctor's appointment before you get it? There's no need to worry – you can always print a temporary ID card. It'll work just as well as the real thing.

Online: Apply online at .CoveredCA.com . Applications are securely transferred directly to your local county social services office, since Medi-Cal is provided at the county level.

This California HIPAA release form enables patients to permit any person or 3rd party organization to have access to their personal health records. The HIPAA release form also optionally allows healthcare providers to share health information with each other.

Telephone Service Center: (800) 541-5555....Beneficiary questions on: Medi-Cal Eligibility. Benefits. Benefits Identification Card.

​ Helpful Hints & Resources Lost or stolen Medi-Cal Beneficiary Identification Cards (BIC): If you have just lost your BIC card, contact your local county worker for a replacement. ... The California Medical Board: (800) 430-4263. Medi-Cal Managed Care Ombudsman: (888) 452-8609. Medi-Cal Billing: (800) 541-5555.

​Medi-Cal Contacts MEDI-CAL PROVIDERPHONE / EMAILMedi-Cal Provider Home Page(800) ​541-5555 (outside of California, please call (916) 636-1980)Provider Overpayments P.O. Box 997425, MS 4720 Sacramento, CA 95899-7425(916) 650-04906 more rows • 2 Sept 2022

If You Do Not Receive Your ID Card or You Lost It Call 1-888-839-9909 (TTY: 711).

​ ​​​​(800) 977-2273​ Medi-Cal Rx ​Members and Providers: If you have a question, need help, or need to report a problem, please call (800) 977-2273 for our Medi-Cal Rx Customer Service Center (CSC)​.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
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Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232