Form DHCS6065A "Good Cause Certification" - California

What Is Form DHCS6065A?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. Check the official instructions before completing and submitting the form.

Form Details:

  • Released on February 1, 2015;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DHCS6065A by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHCS6065A "Good Cause Certification" - California

871 times
Rate (4.3 / 5) 44 votes
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
GOOD CAUSE CERTIFICATION
___________________________________________________ req
uests a waiver of the 30-day Drug Medi-Cal billing limitation for the claims listed below.
COUNTY/DIRECT PROVIDER
Delay Reason Code
:
_______
EDI File Name
:
______________________________________
CLAIM
CLAIM
CLAIM
CLAIM
SUBMITTER'S
FOR
SUBMITTER'S
FOR
IDENTIFIER
MO/YR
IDENTIFIER
MO/YR
Signature: COUNTY/DIRECT PROVIDER REPRESENTATIVE
Date:
Phone Number
)
(
STATE USE ONLY
REVIEWED AND APPROVED FOR DELAY REASON CODES 4 AND 11
Analyst Name:
_______________________________________
Signature: DHCS - FMAB-SUD MANAGER
DHCS 6065A (rev 02/15)
STATE OF CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF HEALTH CARE SERVICES
GOOD CAUSE CERTIFICATION
___________________________________________________ req
uests a waiver of the 30-day Drug Medi-Cal billing limitation for the claims listed below.
COUNTY/DIRECT PROVIDER
Delay Reason Code
:
_______
EDI File Name
:
______________________________________
CLAIM
CLAIM
CLAIM
CLAIM
SUBMITTER'S
FOR
SUBMITTER'S
FOR
IDENTIFIER
MO/YR
IDENTIFIER
MO/YR
Signature: COUNTY/DIRECT PROVIDER REPRESENTATIVE
Date:
Phone Number
)
(
STATE USE ONLY
REVIEWED AND APPROVED FOR DELAY REASON CODES 4 AND 11
Analyst Name:
_______________________________________
Signature: DHCS - FMAB-SUD MANAGER
DHCS 6065A (rev 02/15)