Dhcs 6168 Form – Fill Out and Use This PDF

The DHCS 6168 form, issued by the State of California's Health and Human Services Agency and the Department of Health Care Services, is crucial for individuals who have incurred injuries or illnesses that may involve third-party liability. This form helps in notifying the department about any potential compensation from other parties, such as through lawsuits or insurance claims, which could affect Medi-Cal benefits. Ensuring this form is accurately filled out and submitted is essential for anyone who has used or plans to use Medi-Cal for injury or illness-related expenses. Click the button below to begin the process of filling out your DHCS 6168 form.

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Dhcs 6168 Form PDF Details

When dealing with injuries or illnesses that necessitate medical attention via Medi-Cal, individuals may find themselves navigating the complexities of the DHCS 6168 form. Originating from the State of California’s Health and Human Services Agency, this form plays a crucial role in the Department of Health Care Services’ efforts to manage and recover funds from third parties responsible for injuries. The form seeks essential information about whether Medi-Cal was or will be used for an injury or illness and if there has been or will be a lawsuit or insurance claim related to the incident. It inquires about the location of the injury or illness, details about any lawsuits filed, insurance coverage outside of Medi-Cal/Medicare, and if the injury was work-related, thus involving a workers' compensation claim. This detailed documentation process aids the department in determining potential third-party liabilities and in the recovery program efforts, ensuring that funds are appropriately allocated and reclaimed. Addressing these matters with precision is critical for all parties involved, from the injured individuals to the legal and insurance entities, facilitating a smoother process in managing health care benefits and financial responsibilities.

Question	Answer
Form Name	Dhcs 6168 Form
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	dhs form6168, dhcs 6168, dhcs 6168 forms, dhcs 6168 orm in spanish

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State of Califonria--Health and Human Services Agency			Department of Health Care Services
To: ｕDepartment of Health Care Services		ｕHealth Management Systems	Date:________________
TPL/Personal Injury Unit		WC Recovery Program
Fax: (916) 440-5668	OR	660 J Street, Suite 270	Mail:	Original
		Sacramento, CA 95814	File:	Copy

POTENTIAL THIRD PARTY LIABILITY NOTIFICATION

1.	Have you used, or will you use, Medi-Cal for your injury or illness?	ｕ Yes	ｕ No
2.	Have you filed, or will you file, a lawsuit or insurance claim?	ｕ Yes	ｕ No

If you answered Yes to one or both of the above questions, complete the following:

3.	Injury/illness occurred at: ｕ Home	ｕ School		ｕ On someone else’s property
	ｕ Work	ｕ Motor vehicle		ｕ Other _________________________________

Case name (first, middle, last)						Date of injury or illness (DATE MUST BE PROVIDED.)

Address (number, street)		City		State		ZIP code		Social security number
									–	–

Mailing address		City		State		ZIP code		Telephone number
								(	)
Injured Person(s):
					County		Aid		Social Security Number
	Name		Date of Birth			Code	Code		(If not available, Medi-Cal or CIN)




4.	Have you filed, or will you file, a lawsuit?	ｕ Yes	ｕ No	If yes, please provide the following information:

Attorney name

Mailing address

Telephone number

( )

City	State	ZIP code

5. Is there insurance (other than Medi-Cal/Medicare) covering you or anyone else for this injury/illness (auto, homeowners,

premise liability, accident, health)?

ｕ Yes

ｕ No

If yes, please provide the following information:

Insurance company

Mailing address

Telephone number

( )

City	State	ZIP code

Claim adjuster

Claim/policy number

Policy holder

WORK RELATED INJURY
Have you filed an application for Workers’ Compensation benefits?		ｕ Yes	ｕ No

Employer at time of accident	Telephone number			Workers’ Compensation claim/case number
	(	)

Mailing address	City			State	ZIP code

DO NOT WRITE BELOW THIS LINE

COUNTY USE ONLY

Eligibility worker

Worker number

County

Telephone number

()

DHCS 6168 (2/11)

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2. Once your current task is complete, take the next step – fill out all of these fields - Have you filed or will you file a, ｕ No, If yes please provide the, Attorney name, Mailing address, City, State, ZIP code, Telephone number, Is there insurance other than, ｕ Yes ｕ No, covering you or anyone else for, If yes please provide the, Insurance company, and Mailing address with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

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Dhcs 6168 Form – Fill Out and Use This PDF

Dhcs 6168 Form PDF Details

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