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Pricing Requests Form

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					                                                    Procedure Reimbursement Rates
                 Program: Medi-Cal                     Healthy Families          Healthy Kids              IHSS          AIM
                                         County: Santa Cruz               Monterey             Merced
                                       (Please choose only one program and one county per each request form.)

To:          Central California Alliance for Health – Provider Services Date:
FAX:         (831) 430-5857
From:                                                                                Provider Billing #:
Phone #:                                                                             Rates Requested:
Fax #:                                                                               Contracted            Non-Contracted

Internal Use Only:           Provider Type:                             Specialty:                                  Date Recd:

 Facility or Professional        Procedure Code         Modifier(s)      Place of Service           Contracted Rate       Non-Contracted Rate




Notes:




Rates given are for current pricing. (As of date listed on request form.)
If you would like pricing for another time period please indicate the date of service you are requesting pricing for in the note section.
All pricing requests will be responded to within 3 working days.
                                                         CREATING HEALTHCARE SOLUTIONS
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