Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? 🞎 Yes 🞎 No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service.
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Please attach copy of MEDS. Screen If client is Full scope Mcal, skip the remaining sections of this form and fax to MIS/Billing Unit – 573-2110 Is Client Potentially Eligible for Medi-Cal Benefits? □ Yes □ No Client Referred to Medi-Cal? □ Yes, give date: □ No Is this a Court-ordered Placement? 🞎□ Yes �□ � No Does Client have Medicare? □ Yes □ No If yes, please check all that apply Part A Part B Part D (effective 1/1/06) What is the Client’s Medicare Number? Responsible Party’s Information (Guarantor): Name Phone Relationship to Client □ Self Address City State Zip Code □ Refused to provide Financial Information and will be charged full cost of service.
Appears in 3 contracts