Get Medi-cal Rendering Provider Application/disclosure Statement ...

Filling out the Medi-Cal Rendering Provider Application/Disclosure Statement online can streamline the process of submitting claims and ensure that all necessary information is accurately provided. This guide offers clear, step-by-step instructions to assist you in completing the form with ease.

Follow the steps to complete the application accurately.

1. Press the ‘Get Form’ button to access the Medi-Cal Rendering Provider Application/Disclosure Statement and open it in your preferred editor.
2. Enter your provider name and address in the designated fields at the top of the form. Ensure that the information is typed accurately to avoid delays.
3. Select your claim type by checking only one box from the options provided. This indicates the nature of your resubmission.
4. Fill in your telephone number and Tax ID number in the specified sections. This information is essential for identifying your practice.
5. Complete the section labeled 'Patient's/Member's Name' and provide the member ID number or Social Security Number (SSN) as applicable.
6. Input the claim control number and date of service for the claims you are resubmitting. Accurate details in these fields will facilitate quicker processing.
7. Enter the procedure/modifier code and the amount billed for each claim. Accuracy is crucial to prevent further issues.
8. In the remarks section, provide any necessary corrections or additional information line by line that pertains to previously denied claims.
9. Sign and date the form at the bottom, certifying that the information provided is true and complete.
10. Once completed, save your changes and prepare to print or share the form along with any required attachments before submitting it.

Complete your Medi-Cal Rendering Provider Application/Disclosure Statement online today to ensure efficient processing of your claims.