WebDHCS: CCS Providers may request services for CCS clients using one of the following Service Authorization Request, or SAR, forms: New Referral CCS/GHPP Service Authorization Request (DHCS form 4488) Established Client CCS/GHPP Service Authorization Request (DHCS form 4509) Discharge Planning CCS/GHPP Service … WebE-MAIL OR FAX signed and co mpleted form to: EMAIL: D. [email protected]. or . FAX: (916) 440-5497. ... DHCS 1736 (Rev. 09/2014) Page 2 of 2 State of California - Health and Human Services Agency Department of Health Care Services. Link to mailto:[email protected].
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WebIn addition to completing the DMC Applicaton (Form DHCS 6001, rev. 10/13) and supplying supporting information, applicants must also complete and submit the Medi-Cal … WebMAIL COMPLETED FORM to: Health Care Options or FAX this form to: P.O. Box 989009 (916) 364-0287 Questions? Call 1 (800) 430-4263 West Sacramento, CA 95798-9850 . … birthmark on private part
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WebIn addition to completing the DMC Applicaton (Form DHCS 6001, rev. 10/13) and supplying supporting information, applicants must also complete and submit the Medi-Cal Disclosure Statement (Form DHCS 6207, rev. 7/14). Re-certification is required following relocation of a clinic or satellite site, to add services or funding and/or to WebFor current application fee information, please see the Current Application Fee document on the DHCS website. The Centers for Medicare & Medicaid Services has announced a change in the provider Application Fee for Calendar Year 2024. Medi-Cal Provider Application Fees Preferred Provider Status Returned Warrants Contact Us WebProviders must print, sign, date, and mail the form as per the instructions in the . Form Submission. section. Explanations regarding form fields are located below the form in the . Explanation of Provider Claim Appeal Form . section. Incomplete forms will not be processed and will be returned to the provider. * Indicates Required Field. PART 1 – birthmark on pinky finger