Related links
International Claim Form
Please attach receipts and medical records (test results, x-rays, etc.), if available. Please keep photocopies of all documentation for your personal records.
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New York State Electronic Medicaid
an original claim form. Original Claim Reference Number (Field 4A). Leave this field blank when submitting an original claim or resubmission of a denied claim.
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LTC (25-1) Claim Completion - Medi-Cal
The purpose of this module is to explain the basic requirements for completing the Payment. Request for Long Term Care (25-1) claim form. Common billing errors,
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