XSSTHUCTXGffilS FOR BILLING AB-5 P&TXBHTS
Sha necessary forms ares
^* A.prescriofcion „,fo^_£fr3g~ 1651, This must be signed by 3
a@ the doctor or resident on the caaej
b@ the patient* relative or representative.
2. A^^difial.jlare, Statement fMC-163,)^ This must foe
signed bys
a* the patlent* relative* or representative?
b* the nurse on the ease*
Pertinent znfofeaation §
1. One prescription is good for 5 clays or 15 shifts0
20 *She private duty nurse on the case is to obtain
signatures (on both forms$ of the patient* relative
or representative* She Nursing Office will send the
KG-165 forms to the floor in order to obtain the ! • -
.Doctor°s signature whenever possible* Otherwise*
the private duty niarse is to obtain the signature B.
3@ On a long«tersn casec bills may be submitted weekly
or monthly ({Form MC^163)f as desired.
40 When submitting billss
a, fill out forms as required and cheek for necessary
signaturest (th® patient°s diagnosis should be
added to the MC«165 form as.well as written in
on the KC-163 form}?
bo attach Form MG-165 to Form MC-163^
Co retain last fpink| copies of both forms for
your record$
do mall the forms tos
California Physicians Service
California Medical Assistance Program ■*
720 California Street .
San Francisco 941OSc -----..v KL-tLz *h X^f,
Se Payments should 3r.* aade within 10 days after 5 ?/% ?
receipt of forsaso v -"' * "s • w" e
ES/hb
6/13/66
Orthopaedic Hospital
