RECEIVER AGREEMENT 2026

The document is an Electronic Health Care Claim Payment/Advice Receiver Agreement between the State of California's Department of Health Care Services and Medi-Cal Providers. It outlines the requirements for providers to receive electronic 835-Transactions, including necessary information, obligations, confidentiality, and procedures for designating receivers. The agreement emphasizes compliance with state and federal regulations, responsibilities regarding data accuracy, and conditions for termination.

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Click ‘Get Form’ to open the RECEIVER AGREEMENT in the editor.
Begin by selecting the type of authorization: NEW, CHANGE, or CANCEL. This will determine the nature of your submission.
Fill in the IDENTIFICATION OF PARTIES section with your full legal name and Provider Number. Ensure this information matches what is on file with DHCS.
Complete the PROVIDER INFORMATION section, including your service address and contact details. Double-check for accuracy to avoid processing delays.
In the RECEIVER INFORMATION section, designate up to two entities that will receive the 835-Transaction. Provide their full legal names and necessary identifiers.
Review the BACKGROUND INFORMATION and DEFINITIONS sections to understand your obligations and rights under this agreement.
Finally, sign and date the form in the PROVIDER SIGNATURE INFORMATION section before submitting it through our platform for processing.

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2017	4.8 Satisfied (37 Votes)

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