Electronic Funds Transfer (EFT) Enrollment Form
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Provider Forms
Listed below are all available provider forms for the Medi-Cal Dental program. These forms can be downloaded, printed and mailed.
General
Forms Reorder Request
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Justification for Prosthesis Form
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Medi‐Cal Dental Provider Directory/Referral Form
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EDI
EDI Enrollment Packet
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Cover Sheet
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EDI Enrollment Application
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Electronic Remittance Advice (ERA) Enrollment Form
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Provider Service Office EDI Option Selection Form
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Title 22 Language Pertaining to EDI
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