Provider Billing Information and Attestation Confirmation for ACA Payments

Please complete the following information to be eligible for Affordable Care Act (ACA) payments. This information should include the individual provider's Tax Identification Number (TIN) or Social Security Number (SSN). ACA payments will be sent to the address provided below. Completed information must match that submitted on your W-9.

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* 1. Name (as shown on your income tax return)

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* 2. Business Name/disregard entity name, if different from #1 above

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* 3. Provider NPI

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* 4. Provider SSN/TIN

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* 5. Address (number, street, and apt. or suite number)

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* 6. City, State, and ZIP Code

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* 7. Federal Tax Classification

Individual/Sole Proprietor

C Corporation

S Corporation

Partnership

Trust/Estate

Limited Liability Company

Other (please specify)

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* 8. If a Limited Liability Company, what is the Tax Classification (check below)

C Corporation

S Corporation

Partnership

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* 9. Practice Type aka Specialty (e.g. Internal Medicine, Family Practice)

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* 10. Have you successfully completed the attestation process on the Medi-Cal web site?

I have successfully completed the attestation process on the Medi-Cal web site

I have submitted my attestation form on the Medi-Cal web site and I am awaiting confirmation of my status

I have not yet submitted my attestation form on the Medi-Cal web site

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*Denotes a mandatory response