Dhcs 6168 Form PDF Details

When you are starting a new business, there are a lot of things you need to do in order to get set up. One of the most important is to make sure you are registered with the state, and one of the easiest ways to do this is by filling out Dhcs 6168 form. This form registers your business with the Department of Health and Human Services, and it's essential for making sure your business is legally recognized. Here's everything you need to know about completing this form.

QuestionAnswer
Form NameDhcs 6168 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdhs form6168, dhcs 6168, dhcs 6168 forms, dhcs 6168 orm in spanish

Form Preview Example

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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If you want to fill out this form, make sure you provide the right information in each blank:

1. The dhcs 6168 third party liability notification in spanish usually requires certain details to be inserted. Make sure the subsequent blank fields are complete:

Part # 1 of filling in dhcs 6168 form

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!

Stage no. 2 for completing dhcs 6168 form

It is possible to make a mistake while filling in the State, and so be sure you look again prior to deciding to send it in.

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