Provider Name

REFUND

Provider Name:

Provider Medi-Cal #:

Provider Address:

Provider Phone #:

Recipient/Patient Full Name:

Recipient/Patient Alliance ID # or SS #:

Date/Dates of Service:

Claim Number from Explanation of Benefits:

Refund Amount: Check #:

REASON FOR REFUND - - - PLEASE CHECK APPLICABLE BOX(ES)

Not Our Patient/Wrong Provider

Duplicate Payment (please attach all EOBs that apply)

Wrong Procedure Code

Patient has Other Health Coverage (please attach copy of EOB from OHC/CCS)

Patient has Medicare (please attach copy of EOB from Medicare)

Other (please be specific):

**A COPY OF THIS FORM MUST BE ENCLOSED WITH REFUND**

Please address refund to: CCAH/Recoveries Dept.

1600 Green Hills Rd., Suite 101

Scotts Valley, CA 95066-9998

If you have any questions, please contact the Recoveries Dept. at (831) 430-5500, ext. 5624 or 5622.

Form: CCAH MS-16-1 PEV (Rev: 7/05)