Pharmacy Claim Form (30-1) Completion (pcf30-1 comp) 2026

1. Click ‘Get Form’ to open the Pharmacy Claim Form (30-1) in our editor.
2. Begin by entering the CLAIM CONTROL NUMBER, which is for CA-MMIS FI use only. Leave this area blank as it will be filled by the FI.
3. In the ID QUALIFIER field, input '05' to identify your pharmacy provider.
4. Enter your PROVIDER ID, ensuring not to use a Medicare provider number.
5. Fill in your PROVIDER NAME, ADDRESS, and PHONE NUMBER accurately for processing.
6. Input the nine-digit ZIP CODE that matches your billing information on file.
7. For PATIENT NAME, enter the patient's last name, first name, and middle initial. If billing for a newborn using the mother’s ID number, include specific details as instructed.
8. Complete the MEDI-CAL IDENTIFICATION NUMBER as it appears on the Benefits Identification Card (BIC).
9. Indicate SEX using 'M' for male or 'F' for female based on BIC information.
10. Enter DATE OF BIRTH in MMDDCCYY format from the recipient’s BIC.

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