Crossover Only Provider Form - Dentical Page 3
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4State of California—Health and Human Services Agency
Department of Health Care Services
CROSSOVER ONLY PROVIDER FORM
Important:
FOR STATE USE ONLY
.
Read all instructions before completing the form
Type or print clearly, in ink.
If you must make corrections, please line through, date, and initial in ink.
Do not leave any questions, boxes, lines, etc. blank. Enter N/A if not applicable to
you.
Return completed form to:
Department of Health Care Services
Provider Enrollment Division
MS 4704
P.O. Box 997412
Sacramento, CA 95899-7412
(916) 323-1945
Unless all three of the statements below apply to you, you are not eligible to use this form and must submit a complete
application package.
1. I am a Medicare enrolled provider.
2. I have provided services to a dual-eligible beneficiary. (see instructions for definition)
3. I am requesting authorization to submit claims for reimbursement for services provided to a dual-eligible beneficiary, requesting a change to
previously submitted information or I am requesting a deactivation of my provider file.
__________________________________________________________________________________________________________________________
DATE
:
NPI used for billing Medicare:
Previously submitted NPI (if applicable):
PTAN (Medicare Identification Number):________________________________________________
(Attach a copy of your Centers for Medicare and Medicaid Services [CMS] provider approval letter.)
Action requested (check[ ] if applicable)
New request
Change to previously submitted information
Deactivation of provider file
I. PROFESSIONAL INFORMATION
Type of entity
Nonprofit Corporation—Type of nonprofit:
Sole Proprietor (unincorporated)
Partnership
_____________________________________________________
Professional Medical Corporation—Corporate
Other:
Number:________________________________
_____________________________________________________
1a. Legal name of provider (as listed with the IRS)
1b. Previously submitted legal name (if applicable)
2a. Business name, if different from legal name
2b. Business telephone number
(
)
2d. Previously submitted business telephone number
2c. Previously submitted business name (if applicable)
( if applicable)
(
)
3a. Business address (number, street)
City
County
State
Nine-digit ZIP code
3b. Previously submitted Business address (number, street)
City
County
State Nine-digit ZIP code
(if applicable)
4a. Pay-to address (number, street)
City
State
Nine-digit ZIP code
Page 3 of 4
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