Crossover Only Provider Form - Dentical Page 4
Download a blank fillable Crossover Only Provider Form - Dentical in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Crossover Only Provider Form - Dentical with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4State of California—Health and Human Services Agency
Department of Health Care Services
4b. Previously submitted pay-to address (number, street) (if applicable)
City
State
Nine-digit Zip code
5a. Mailing address (number, street)
City
State
Nine-digit ZIP code
5b. Previously submitted mailing address (number, street) (if applicable)
City
State
Nine-digit ZIP code
6a. Primary Taxonomy Code
6b. Taxonomy Code
6c. Taxonomy Code
6d. Previously submitted taxonomy code (if applicable)
7a. Taxpayer Identification Number (EIN, ITIN) (attach
7b.Previously submitted TIN (EIN, ITIN) (if applicable)
7c. Social Security Number (if applicable)
copy of EIN verification or ITIN notification letter)
___ ___ ___ — ___ ___ — ___ ___ ___ ___
8. Provider Type (see instructions)
9a. Professional license number (if applicable)
9b. Professional license state of issuance
10. Explanations or other information you wish to provide (attach additional pages if needed)
II. Signature
1. Printed legal name
(last)
(first)
(middle)
(Jr., Sr., etc.)
2. Printed name of representative (if an entity or business name is checked above) (last)
(first)
(middle)
(Jr., Sr., etc.)
3. Original signature of provider or representative (if this provider is an entity other than an individual or sole proprietor)
Executed at:
,
on
(city)
(state)
(date)
4. Representative/ Contact person’s information
Contact person’s name
(last)
(first)
(middle)
(gender)
male
female
Title/Position
E-mail address
Telephone number
(
)
Page 4 of 4
MC 0804 (10/10)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical