Fillable Medi-Cal Forms Order Form (Department of Health Care Services)

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Medi-Cal Forms Order Form (Department of Health Care Services)

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State of California Health and Human Services Agency Department of Health Care Services
Order Form
Medi-Cal Forms
To process your orders fax to the following:
FAX: (916) 552-9477
Date
Name of County
Contact Person Name
Phone Number
Email address
Department/Agency/Facility
Section
Street address only – Do Not use P. O. Box
City
State
Zip code
Item/Publication Title
Item Suffix
Unit
MC 0244 (06/13)
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Medi-Cal Forms Order Form (Department of Health Care Services)

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Completed 23 November 2020

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