Fillable Provider Registration for Claims Submission (CalOptima)

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Provider Registration for Claims Submission (CalOptima)

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The Provider Registration for Claims Submission (CalOptima) form is 1 page long and contains:

  • 0 signatures
  • 3 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

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Provider Registration for Claims Submission
Rendering Provider
Name
Rendering Provider NPI
Provider Type
☐ Provider
☐ Group with Practitioner(s)
☐ Facility
Group Name
(if applicable)
Group Billing NPI
(if applicable)
Provider State License
Number
Provider Specialty
Service Address
City, State, ZIP
Phone Number
Remit Address
Tax ID Number
(Submit W-9)
Contact Person
Name:
Phone:
Email:
Forward completed form along with a W-9 to Provider Data Management Services
via fax at 714-954-2330 or email to provideronline@caloptima.org.
All completed requests received will be processed within seven business days.
If you have any questions, contact the Provider Data Management Services at 714-246-8468.
All calls will be returned within one business day.
If approved for COVID 19 Emergency Medi-Cal Provider Enrollment, please include the
Department of Health Care Services (DHCS) approval letter.
Thank you,
Provider Data Management Services
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Provider Registration for Claims Submission (CalOptima)

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Completed 11 March 2021

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