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Click ‘Get Form’ to open the mc1054 form in the editor.
Begin by entering the provider name and address at the top of the form. This information is crucial for identifying your practice.
Fill in the notice date, case name, and case number in their respective fields. Ensure accuracy as these details are essential for processing.
Next, provide the EW (Eligibility Worker) name, number, address, and telephone number. This information helps facilitate communication regarding Medi-Cal eligibility.
In the section detailing share-of-cost changes, list each month/year along with original and revised SOC amounts. This is vital for tracking adjustments.
Review all entries for accuracy before submitting. Once completed, save your changes and export or share the document as needed.
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