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Pharmacy Claim Form (30-1) Completion (pcf30-1 comp) 2026
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- Click ‘Get Form’ to open the Pharmacy Claim Form (30-1) in our editor.
- 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.
- In the ID QUALIFIER field, input '05' to identify your pharmacy provider.
- Enter your PROVIDER ID, ensuring not to use a Medicare provider number.
- Fill in your PROVIDER NAME, ADDRESS, and PHONE NUMBER accurately for processing.
- Input the nine-digit ZIP CODE that matches your billing information on file.
- 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.
- Complete the MEDI-CAL IDENTIFICATION NUMBER as it appears on the Benefits Identification Card (BIC).
- Indicate SEX using 'M' for male or 'F' for female based on BIC information.
- Enter DATE OF BIRTH in MMDDCCYY format from the recipient’s BIC.
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