Get Ca Mc 0804 2010-2025

This guide provides clear, step-by-step instructions for completing the CA MC 0804 form online. Whether you are new to this process or seeking to update your information, this guide will help you navigate each component successfully.

Follow the steps to complete the CA MC 0804 online effectively.

1. Click the ‘Get Form’ button to obtain the CA MC 0804 and open it in the online editor.
2. Enter the date you are completing the form. This should be the current date when you are filling out the application.
3. Provide your National Provider Identifier (NPI) number. This must correspond to the business address you will enter later.
4. If applicable, fill in the Previously Submitted NPI Number. Only provide this if your NPI has changed since your last submission.
5. Enter your PTAN (Provider Transaction Access Number) which is assigned to you by the Centers for Medicare and Medicaid Services (CMS). Be sure to attach your CMS approval letter.
6. Select the Action Requested by checking the applicable box for ‘New request,’ ‘Change to previously submitted information,’ or ‘Deactivation’.
7. In the Professional Information section, check the type of entity that represents your business structure.
8. Provide your legal name as listed with the IRS, and if applicable, your previously submitted legal name.
9. Fill in your business name, if it differs from your legal name, and include your primary business telephone number.
10. Enter the full business address, ensuring to include all relevant details such as the street address, city, county, state, and ZIP code.
11. If your business has moved, provide the previously submitted business address, if applicable.
12. Fill out the Pay-to address, Mailing address, and any changes in previously submitted addresses as necessary.
13. Enter the Taxpayer Identification Number (TIN), and if applicable, supply the previously submitted TIN.
14. Indicate your Provider Type by selecting the category that best describes your professional service.
15. If you have a professional license, include that number and the state of issuance.
16. Any additional explanations or pertinent information can be entered in the designated section on the form.
17. In the signature section, print the name of the provider and the representative if applicable, along with their original signature, date, and place of signing.
18. Finally, enter the contact information of a representative who can address questions regarding the form for the Provider Enrollment staff.
19. Once all fields are correctly filled, you can save your changes, download, print, or share the completed form.

Begin the process of filling out the CA MC 0804 online to ensure your application is submitted without delays.