State of California—Health and Human Services Agency Department of Health Care Services FORMS ORDER—P by ebj11165

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									State of California—Health and Human Services Agency                                                                   Department of Health Care Services




                        FORMS ORDER—PRESUMPTIVE ELIGIBILITY (PE)

Provider Name                                          NPI Number         Medi-Cal Number         Authorization Code       PE Provider Number



Shipping address (Number, street) (No P.O. Boxes)                         City                            State            Zip Code
                                                                                                          CA

Provider telephone number                                                 Contact person


7256108
INSTRUCTIONS: In the boxes below, please indicate the number of forms requested. Be sure to indicate whether English
and/or Spanish forms are being requested.
725-6108
To order the PREMED Application Package MC 263, fax this completed order form to 1-800-409-1498 or mail to:

                                                   PE for Pregnant Women Support
                                                   Department of Health Care Services
                                                   Medi-Cal Eligibility Division, MS 4607
                                                   P.O. Box 997417
                                                   Sacramento, CA 95899-7417

NOTE: Please remember, when indicating the number of MC 263 PREMED packages requested, that these packages are
pre-numbered and cannot be copied. The order may take up to eight weeks before delivery.


                                                                         QUANTITY                   QUANTITY                       QUANTITY
                                                                          TOTAL                     ENGLISH                        SPANISH
                 FORM NAME AND NUMBER




 MC 263–PREMED Package



This order form is available from the Department of Health Care Services (DHCS) or Medi-Cal website at:

                         DHCS               www.dhcs.ca.gov
                         Medi-Cal           www.medi-cal.ca.gov


The following supplemental PE forms are also available from the DHCS or Medi-Cal websites.

                                                   MC 263–SR        Statement of Residency
                                                   MC 264           Patient Fact Sheet
                                                   MC 265           Directions for PE Application
                                                   MC 266           Directions for Medi-Cal Application
                                                   MC 267           Explanation of Ineligibility for PE
                                                   MC 283           Weekly PE Enrollment Summary
                                                   MC 286           Provider Fact Sheet for PE

If you are unable to download the above forms from the websites, please call PE Support toll free at
1 (800) 824-0088 or fax 1 (800) 409-1498, and a copy will be mailed or faxed to you.




MC 285 (08/10)

								
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