Transcription of INSTRUCTIONS FOR COMPLETING THE FORM - dhcs.ca.gov
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INSTRUCTIONS FOR COMPLETING THE FORM - dhcs.ca.gov
NON-DRUG MEDI-CAL EXISTING PROVIDER INFORMATION UPDATE/CHANGE FORMINSTRUCTIONS FOR COMPLETING THE form The information furnished in this form will be used to update existing provider information in the Department of Health Care Service s Master Provider File (MPF) database (also known as PRIMe). Therefore, the integrity and accuracy of the information provided is critical. Please READ ALL INSTRUCTIONS before filling out this form . This is a fillable pdf form . You must have the free Adobe Acrobat Reader software downloaded to fill in the fields. Download it here: Otherwise, please PRINT or TYPE all information so it is legible. You can click the PRINT button at the top of each page to print the form to fill it in by hand or use a typewriter. If filling in by hand, use only blue or black ink. Do not use pencil. Failure to provide complete and accurate information may cause your form (s) to be returned and delay processing. Please fill out one form per request type. For example, if you have multiple providers for whom you want the same servicetype change made, you must fill out one form for each provider.
instructions for completing the form The information furnished in this form will be used to update existing provider information in the Department of Health Care Service’s Master Provider File (MPF) database (also known as PRIMe).
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