Fillable Mc2213 Financial Card

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Mc2213 Financial Card

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State of California—Health and Human Services Agency Department of Health Care Services
MC
2213 (09/07)
FINANCIAL CARD
Name (last, first, middle) Birth date (month, day, year) Case number
Diagnosis Insurance Medi-Cal number Effective date County
Date of Posting Provider Service Dates and Codes
Treatment
Expenditure
Insurance
Paid Remarks
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Mc2213 Financial Card

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Completed 3 July 2020

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