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Get Health Net Provider Dispute Form

Provide additional information to support the description of the dispute. Do not include a copy of a claim that was previously processed. For routine follow-up, use the Provider Inquiry Request form instead of this form. Mail the completed form to the following addresses. Please note the specific address for all Medi-Cal appeals. Health Net Medi-Cal Provider Appeals Unit Health Net Provider Appeals Unit P.O. Box 10406 Van Nuys, Ca 91410-0406 11971 Foundation Place Rancho Cordova, Ca 95670 (.

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