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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.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/caloptima-notification-of-change-of-pay-to-address-form-rev-06012001/302102/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/caloptima-notification-of-change-of-pay-to-address-form-rev-06012001/302102.png","ImageObject",442,249,{"name":88,"@type":89},"eBook King","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-21","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":9},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What information is required to change the “pay-to” address?","Question",{"text":108,"@type":109},"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.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"Does the form require notarization?",{"text":113,"@type":109},"Yes. The signature must be signed, notarized, and returned, including the notary public’s signature section.",{"name":115,"@type":106,"acceptedAnswer":116},"Where should completed forms be returned?",{"text":117,"@type":109},"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.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},302102,1790033324,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":9,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":9},962088006270,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","CalOptima NOTIFICATION OF CHANGE OF “PAY TO” ADDRESS FORM  \nI hereby request that the pay-to address of    \n(LTC Facility Name)  \n(LTC Facility Medi-Cal Number) (Effective Date of Change MM/DD/YY)  \nIs this a new billing company?  Yes  No Ifyes is checked please provide billing company name in new address.  \nOld Address:  \n____________________________________________________________________________  \n____________________________________________________________________________  \nNew Address/Billing Company Name :    \n____________________________________________________________________________  \n____________________________________________________________________________  \nI 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.  \nI (WE), THE UNDERSIGNED, HAVE READ THIS RELEASE AND FULLY UNDERSTAND IT.  \nDated this   day of   , 20   ,  \nFederal Tax ID\\#:      \nAuthorized Signature  \nTitle and Phone Number  \nCorporation Name  \nState of Caoflifornia }ss   \nCounty  \nOn   , before me,   , personally Date  \nappeared   ,  personally know to me  proved to me on the basis of satisfactory evidence  \nto 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.  \nThis form must be signed, notarized and returned to  \nSignature of Notary Public  \nCalOptima Provider Enrollment  \nP.O. Box 11033 Orange, CA 92856  \nPh: 714-246-8468 Fax: 714-246-8448  \nNote: 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.  \nRev. 06.01.2001  \nCalOptima NOTIFICATION OF CHANGE OF FEDERAL TAX I.D. FORM  \nI hereby request that the Federal Tax I.D. number of    \n(LTC Facility Name)  \n(LTC Facility Medi-Cal Number and Reason for change)  \nBe changed from Old Federal Tax I.D. \\# :   Effective Date   \nTo New Federal Tax I.D. \\#:   Effective Date (New W-9 must be submitted with this form )  \nI 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.  \nI (WE), THE UNDERSIGNED, HAVE READ THIS RELEASE AND FULLY UNDERSTAND IT.  \nDated this   day of   , 20   , Pay To Address:  \n___________________________________  \n___________________________________  \n\n| Authorized Signature |\n| --- |\n| Title and Phone Number |\n\nCorporation Name  \nState of  \nCounty  \nCaoflifornia }ss .  \nOn   , before me,   , personally Date  \nappeared   ,  \n personally know to me  proved to me on the basis of satisfactory evidence  \nto 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.  \nThis form must be signed, notarized and returned to  \nSignature of Notary Public  \nCalOptima Provider Enrollment  \nP.O. Box 11033 Orange, CA 92856  \nPh: 714-246-8468 Fax: 714-246-8448  \nNote: 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","cbCaimecStFlq6k4","https://ap.wps.com/l/cbCaimecStFlq6k4","pdf",172787,"English","# Pay-To Address Change Request\n## Billing Company Check\n## Old Address and New Address/Billing Company Name\n## Release Statement and Signature\n## Notary Section\n# Federal Tax I.D. Change Request\n## Reason for Change and Effective Dates\n## Release Statement and Signature\n## Notary Section","[{\"question\":\"What information is required to change the “pay-to” address?\",\"answer\":\"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.\"},{\"question\":\"Does the form require notarization?\",\"answer\":\"Yes. The signature must be signed, notarized, and returned, including the notary public’s signature section.\"},{\"question\":\"Where should completed forms be returned?\",\"answer\":\"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.\"}]","CalOptima - Notification of Change of Pay-To Address Form - Rev. 06.01.2001 | PDF",1789789032]