Revised 10/16/19
Notification of Change of Federal Tax I.D. Form
I/We, _______________________________________________________________________________________________,
(Provider Name)
_________________________________________, hereby request that my/our Federal Tax I.D. number be changed
(Medi-Cal Number)
From Old Federal Tax I.D. #: ____________________________________________________________________________
To New Federal Tax I.D. #: ______________________________ Effective Date: .
___________________________ _______
(MM/DD/YY)
(NEW W-9 MUST BE SUBMITTED WITH THIS FORM)
Reason for Change:
Ownership Change Other (specify):____________________________________________
I/We hereby unconditionally release and forever discharge CalOptima and each and all of its agents, officers, and employees
from any and all claims, damages, costs, expenses and rights to compensation whatsoever, which I/we now have or which
may hereafter accrue on account of, or in any way as a result of, this notice of change of Federal Tax I.D. number.
I (WE), THE UNDERSIGNED, HAVE READ THIS RELEASE AND FULLY UNDERSTAND IT.
Dated this ________________________________ day of __________________________________________, 20 ________,
Pay To Address: ____________________________________________________
___________________________________________ Authorized Signature
____________________________________________________
___________________________________________ Title
____________________________________________________
Corporation Name
State of California
County of _______________________________
On _______________________________, before me, ______________________________________________, personally
Date
appeared____________________________________________________________________________________________,
personally known to me proved to me on the basis of satisfactory evidence
to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in
his/her authorized capacity, and that by his/her signature on the instrument the person or the entity upon behalf of which the
person acted, executed the instrument.
________________________________________
Signature of Notary Public
This form must be signed, notarized and returned to: CalOptima Provider Data Management Department
505 City Parkway West
Orange, CA 92868
Email: provideronline@caloptima.org
Ph: 714-246-8468 Fax: 714-954-2330
Note: Any change of Federal Tax I.D. Number for long-term care or inpatient/outpatient providers must be processed by
the local Licensing and Certification Division of the Department of Health Services. If you cannot contact the local branch,
call Licensing and Certification headquarters in Sacramento at 916-445-2070 for more information.
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