CalOptima - Notification of Change of Pay-To Address Form - Rev. 06.01.2001

Sep 19, 2026

CalOptima notification forms request updates to billing-related information for a Long Term Care facility, including the “pay-to” address and, in a separate section, changes to the Federal Tax I.D. number. The forms capture facility identifiers, effective dates, old and new address or tax information, and whether a new billing company is involved. They require an authorized signature, title and phone number, corporation name, and notarization, and include a release statement discharging CalOptima and its agents from related claims.

LanguageEnglish

CategoryForms

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

Pay-To Address Change Request

Billing Company Check

Old Address and New Address/Billing Company Name

Release Statement and Signature

Notary Section

Federal Tax I.D. Change Request

Reason for Change and Effective Dates

Release Statement and Signature

Notary Section

CalOptima NOTIFICATION OF CHANGE OF “PAY TO” ADDRESS FORM I hereby request that the pay-to address of (LTC Facility Name) (LTC Facility Medi-Cal Number) (Effective Date of Change MM/DD/YY) Is this a new billing company? Yes No Ifyes is checked please provide billing company name in new address. Old Address: ____________________________________________________________________________ ____________________________________________________________________________ New Address/Billing Company Name : ____________________________________________________________________________ ____________________________________________________________________________ I hereby unconditionally release and forever discharge CalOptima and each and all of its agents, officers, and employees from any and all claims, damages, costs, expenses, and rights to compensation whatsoever, which I now have or which may hereafter accrue on account of, or in any way as a result of this notice of change of address. I (WE), THE UNDERSIGNED, HAVE READ THIS RELEASE AND FULLY UNDERSTAND IT. Dated this day of , 20 , Federal Tax ID\#: Authorized Signature Title and Phone Number Corporation Name State of Caoflifornia }ss County On , before me, , personally Date appeared , personally know to me proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person orthe entity upon behalf of which the person acted, executed the instrument. This form must be signed, notarized and returned to Signature of Notary Public CalOptima Provider Enrollment P.O. Box 11033 Orange, CA 92856 Ph: 714-246-8468 Fax: 714-246-8448 Note: Any change of “Service” address for Long Term Care or Inpatient/Outpatient providers must be processed by the local Licensing and Certification Division of the Department of Health Services. If you cannot contact the local branch, call Licensing and Certification headquarters in Sacramento at (916) 445-2070 for more information. Rev. 06.01.2001 CalOptima NOTIFICATION OF CHANGE OF FEDERAL TAX I.D. FORM I hereby request that the Federal Tax I.D. number of (LTC Facility Name) (LTC Facility Medi-Cal Number and Reason for change) Be changed from Old Federal Tax I.D. \# : Effective Date To New Federal Tax I.D. \#: Effective Date (New W-9 must be submitted with this form ) I hereby unconditionally release and forever discharge CalOptima and each and all of its agents, officers, and employees from any and all claims, damages, costs, expenses, and rights to compensation whatsoever, which I now have or which may hereafter accrue on account of, or in any way as a result of this notice of change of Federal Tax I.D. number. I (WE), THE UNDERSIGNED, HAVE READ THIS RELEASE AND FULLY UNDERSTAND IT. Dated this day of , 20 , Pay To Address: ___________________________________ ___________________________________ | Authorized Signature | | --- | | Title and Phone Number | Corporation Name State of County Caoflifornia }ss . On , before me, , personally Date appeared , personally know to me proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to the within instrument and acknowledged to me that he/she executed the same in his/her authorized capacity, and that by his/her signature on the instrument the person or the entity upon behalf of which the person acted, executed the instrument. This form must be signed, notarized and returned to Signature of Notary Public CalOptima Provider Enrollment P.O. Box 11033 Orange, CA 92856 Ph: 714-246-8468 Fax: 714-246-8448 Note: Any change of Federal Tax I.D. Number for Long Term Care or Inpatient/Outpatient providers must be processed by the local Licensing and Certific

FAQs

What information is required to change the “pay-to” address?

Provide the LTC facility name, LTC facility Medi-Cal number, effective date, old address, and the new address or billing company name. Indicate whether it is a new billing company and include the name if yes.

Does the form require notarization?

Yes. The signature must be signed, notarized, and returned, including the notary public’s signature section.

Where should completed forms be returned?

Return the signed and notarized form to CalOptima Provider Enrollment, P.O. Box 11033, Orange, CA 92856. The form also provides phone and fax numbers for CalOptima.

Sep 19, 2026

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