Form Mc 2213 - Financial Card
Download a blank fillable Form Mc 2213 - Financial Card in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Mc 2213 - Financial Card with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1Department of Health Care Services
State of California—Health and Human Services Agency
FINANCIAL CARD
Name (last, first, middle)
Birth date (month, day, year)
Case number
Diagnosis
Insurance
Medi-Cal number
Effective date
County
Treatment
Insurance
Date of Posting
Provider
Service Dates and Codes
Expenditure
Paid
Remarks
MC 2213 (09/07)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Mc 280 Tb - Tuberculosis (tb) Program Financial Eligibility Work Sheet-eligible Child With Ineligible Parent Or Parent(s)
Legal
Forms Mc 6013 And Mc 6014 And Mc 6004 - Instructions For Completing Dmc Forms For Odf Group And Individual - Perinatal
Legal
Related Categories
Parent category: Legal