Fillable Consent and Agreement to Offset Monies Owed to (CalOptima)

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Consent and Agreement to Offset Monies Owed to (CalOptima)

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The Consent and Agreement to Offset Monies Owed to (CalOptima) form is 1 page long and contains:

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  • 13 other fields

Country of origin: US
File type: PDF

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505 City Parkway West | Orange, CA 92868 | www.caloptima.org
Main: 714-246-8400 | Fax: 714-246-8492 | TDD/TTY: 800-735-2929
Consent and Agreement to Offset Monies Owed to
CalOptima
Provider Name:
NPI:
Tax ID:
Phone Number:
Member Name:
Member Account Number:
Claim Number:
Overpaid Amount:
Date of Service(s):
Reason of Consent to Offset
Money (Please Specify):
I am authorized to sign on behalf of the provider listed above and authorize CalOptima to offset the
amount owed from future payments.
Name (Please Print):
Title:
Signature:
Date:
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Consent and Agreement to Offset Monies Owed to (CalOptima)

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Completed 11 March 2021

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