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Get CA Medi-Cal Provider Manual

68 Instructions on completing the Appeal Form: Each numbered item below refers to an area on the Medi-Cal Appeal Form shown on the previous page. Item Description 1. Appeal Reference Number. For PHC use only. 2. Document Number. The pre-imprinted number identifying the Appeal Form. 3. Provider Name/Address. Enter the following information: Provider Name, Street Address, City, State, and ZIP code. 4. Provider Number (Required Field). Enter your provider number/National Provider Identifi.

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