Common use of CONFIDENTIALITY OF RECORD Clause in Contracts

CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi- Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. PROVIDER SIGNATURE INFORMATION Full printed name Title Provider signature (original signature required; DO NOT use black ink)  Date BILLING SERVICE SIGNATURE INFORMATION (complete only if “Xxxxxx Information” is completed on page 1 of 5) Full printed name Title Owner or Corporate Officer signature (original signature required; DO NOT use black ink)  Date Return Application/Agreement to: California MMIS Fiscal Intermediary CMC Unit P.O. Box 15508 Sacramento, CA 95852-1508 Privacy Statement (Civil Code Section 1798 et seq.)

CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi- Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. PROVIDER SIGNATURE INFORMATION Full printed name Title Provider signature (original signature required; DO NOT use black ink)  Date BILLING SERVICE SIGNATURE INFORMATION (complete only if “Xxxxxx Information” is completed on page 1 of 5) Full printed name Title Owner or Corporate Officer signature (original signature required; DO NOT use black ink)  Date Return Application/Agreement to: California MMIS Fiscal Intermediary CMC Unit P.O. Box 15508 SacramentoX.X. Xxx 00000 Xxxxxxxxxx, CA 95852XX 00000-1508 0000 Privacy Statement (Civil Code Section 1798 et seq.)

CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi- Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. PROVIDER SIGNATURE INFORMATION Full printed name Title Provider signature (original signature required; DO NOT use black ink)  ✍ Date BILLING SERVICE SIGNATURE INFORMATION (complete only if “Xxxxxx Information” is completed on page 1 of 5) Full printed name Title Owner or Corporate Officer signature (original signature required; DO NOT use black ink)  ✍ Date Return Application/Agreement to: California MMIS Fiscal Intermediary CMC Unit P.O. Box X.X. Xxx 15508 Sacramento, CA 95852-1508 Privacy Statement (Civil Code Section 1798 et seq.)

CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi- Medi-Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. PROVIDER SIGNATURE INFORMATION Full printed name Title Provider signature (original signature required; DO NOT use black ink)  Date BILLING SERVICE SIGNATURE INFORMATION (complete only if “Xxxxxx Information” is completed on page 1 of 51) Full printed name Title Owner or Corporate Officer signature (original signature required; DO NOT use black ink)  Date Return Application/Agreement to: California MMIS Fiscal Intermediary CMC Unit P.O. Box 15508 SacramentoX.X. Xxx 00000 Xxxxxxxxxx, CA 95852XX 00000-1508 0000 Privacy Statement (Civil Code Section 1798 et seq.)

CONFIDENTIALITY OF RECORD. The Provider/Xxxxxx agrees to provide adequate precautions to protect the confidentiality of Medi- Medi-Cal beneficiary record and claims submission methods in accordance with statute or regulations Title 17, CCR, Section 6800, et seq. and/or 42 CFR, Part 400 and 440, Subpart B. PROVIDER SIGNATURE INFORMATION Full printed name Title Provider signature (original signature required; , DO NOT use black ink)  Date BILLING SERVICE SIGNATURE INFORMATION (complete only if “Xxxxxx Information” is completed on page 1 of 51) Full printed name Title Owner or Corporate Officer signature (original signature required; , DO NOT use black ink)  Date Return Application/Agreement to: California MMIS Fiscal Intermediary CMC Unit P.O. Box 15508 SacramentoX.X. Xxx 00000 Xxxxxxxxxx, CA 95852XX 00000-1508 0000 Privacy Statement (Civil Code Section 1798 et seq.)