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Get MPMG PDR 2004-2024

are required. Be specific when completing the DESCRIPTION OF DISPUTE and EXPECTED OUTCOME. Provide additional information to support the description of the dispute. Do not include a copy of a claim that was previously processed. For standard questions and claims adjustments, you may call MPMG Customer Service at 650-240-8059. Mail the completed form to: MPMG Provider Dispute Unit P. O. Box 4348 Burlingame, CA 94010-4348 Fax the completed form to: 650-240-0900 *PROVIDER NAME: *PROVIDER TAX ID .

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