Dhcs 6172 Form PDF Details

The DHCS 6172 form, issued by the State of California's Health and Human Services Agency, Department of Health Care Services, is a crucial document for Medi-Cal beneficiaries who aim to apply for Health Insurance Premium Payment (HIPP). It serves multiple purposes, including providing essential personal information such as the name of the applicant, beneficiary's address, social security number, and details about the health insurance policy like the insurance carrier's name, policy number, coverage types, and how insurance premiums are paid. Furthermore, it addresses how often premiums are paid, the current status of the policy, and if the policy is paid through COBRA. This form requires applicants to disclose whether their coverage includes a range of medical services from hospital stays, prescription drugs, vision care, to long term care, among others. It also inquires about high-cost medical conditions requiring physician treatment, emphasizing the importance of gathering comprehensive data to assist in the administration of Medi-Cal benefits. The form mandates the assignment of rights to medical insurance, support, or third-party payments to the Medi-Cal program, ensuring cooperation with the Department in obtaining medical support or payments and allowing for the recovery of funds when services paid by Medi-Cal could have been billed to other insurance providers. Additionally, it outlines the confidentiality and use of provided information in compliance with the Federal Privacy Act and Welfare Institutions Code, underscoring the program's commitment to privacy and the responsible management of sensitive information. Completing and submitting this form is a step towards receiving assistance with health insurance premiums, making it a key component for eligible Medi-Cal beneficiaries seeking financial support for their healthcare needs.

QuestionAnswer
Form Name Dhcs 6172 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names medical for families number, medical for families payments, medical for families online payment, dhcs premium payments

Form Preview Example

Paid by policyholder directly to insurance carrier
$
11. Current policy status (check and fill in date, if applicable)
9. Current premium amount
7. Premium billing location (where premiums are mailed)
8. Policy number
City
City
1. Name of applicant/Medi-Cal beneficiary
4. Beneficiary’s address
5. Name of insurance carrier

State of California–Health and Human Services Agency

Department of Health Care Services

HEALTH INSURANCE PREMIUM PAYMENT APPLICATION

(See instructions for completing on reverse)

2. Social Security number

3. Telephone number

()

State

ZIP code

6. Insurance carrier’s telephone number

()

State

ZIP code

10. How often is it paid (check which applies)

Monthly

Quarterly

Other:

 

COBRA

Yes

No

Policy is paid through:

 

 

Policy lapsed on:

 

 

12.

Type of coverage your insurance provides (check all that apply)

 

 

 

 

 

 

 

 

Hospital stays

 

 

 

 

Prescription drugs

Long Term Care (LTC)

 

 

Hospital outpatient (i.e., lab work or physical therapy)

 

Vision care

Medicare supplement policy

 

Doctor visits

 

 

 

 

Dental care

 

 

 

 

13.

Name of policyholder

 

 

 

 

 

14. Policyholder’s Social Security number

 

 

 

 

 

 

 

 

 

 

15. Policyholder’s address

 

 

City

 

State

ZIP code

 

16. Policyholder’s telephone number

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

17.

Is the policyholder court ordered to provide the medical insurance?

Yes

18. Is the policy a Medicare Supplement?

Yes

 

 

 

 

 

 

No

 

 

 

 

No

19.

How are the insurance premiums currently paid (check which applies)

 

 

 

 

 

 

 

 

Paid ENTIRELY by employer

 

 

Paid by policyholder through payroll deduction

Other:

 

Paid ENTIRELY by an absent parent

20. Name and Social Security Number of other family members covered by Medi-Cal AND the private insurance listed in item 5:

 

 

Name

 

 

Social Security Number

_______________________________________________________________________________________________________

_______________________________

_______________________________________________________________________________________________________

_______________________________

_______________________________________________________________________________________________________

_______________________________

_______________________________________________________________________________________________________

_______________________________

 

 

 

 

 

 

21.

Policyholder’s employer

 

 

 

22. Employer’s telephone number

 

 

 

 

 

(

)

 

 

 

 

 

 

 

23.

Employer’s address

City

State

 

ZIP code

 

 

 

 

 

 

 

 

24. Does anyone listed on this application have a high-cost medical condition that requires a physician’s treatment? If so, list the name and type of illness (use additional paper if necessary).

________________________________________________

_______________________________

___________________________

_______________________

Name

Illness

Name

Illness

IMPORTANT: As a condition of eligibility, all Medi-Cal beneficiaries shall assign rights to medical insurance, support, or other third-party payments to the Medi-Cal program and shall cooperate with the California Department of Health Care Services in obtaining medical support or payments. The assignment of rights to benefits is effective only for services paid for by the Medi-Cal program. Assignment of medical rights allows the California Department of Health Care Services to recover funds from health insurance companies or funds when the Medi-Cal program pays for medical services, which should have been billed to other health insurance coverage. Please note that in order to comply with the Federal Privacy Act (42USC, Section 552a) your Social Security Number and any information you provide may be used to contact insurance companies, employers, providers of health care services, and county agencies to determine the extent of available health insurance. Under Welfare and Institutions Code, Section 14100.2, any submitted information is considered confidential and disclosed only as necessary for Medi-Cal program administration purposes.

AUTHORIZATION: “I hereby authorize the California Department of Health Care Services to obtain, if needed, any information regarding my private health insurance coverage, including payments and/or benefits for medical care made in my behalf, which may be used in determining if the California Department of Health Care Services will pay health insurance premiums for continued coverage.”

25. Signature of Medi-Cal Beneficiary

Date

DHCS 6172 (12-07)

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State of California–Health and Human Services Agency

Department of Health Care Services

INSTRUCTIONS FOR COMPLETING THE

HEALTH INSURANCE PREMIUM PAYMENTAPPLICATION

FORM DHCS 6172

The following instructions are to be used in completing the Health Insurance Premium Payment application. PLEASE PRINT THE INFORMATION.

1.Enter your full name.

2.Enter your nine-digit Social Security number.

3.Enter your complete daytime telephone number, including area code. If you do not have a telephone number, please enter a message telephone number in the telephone number box and indicate, “message.”

4.Enter your complete street address, city, state, and zip code.

5.Enter the name of your current health insurance carrier.

6.Enter the telephone number, including area code, of your health insurance carrier.

7.Enter the complete street address, city, state, and zip code where your premiums are mailed.

8.Enter your health insurance policy number.

9.Enter your current health insurance premium amount.

10.Indicate how often you pay your health insurance premiums by checking the appropriate box.

11.Indicate if your health insurance is being paid through COBRA by checking the yes or no box. Also, indicate the date your policy is paid through. If your policy has lapsed within the last 90 days, indicate the date the policy lapsed.

12.Indicate, by entering a checkmark in the appropriate box(es), the medical services that are covered by your health insurance policy.

13.Enter the full name of the insured/policyholder. This is the name of the person to whom the policy was issued.

14.Enter the nine-digit Social Security number of the policyholder.

15.Enter the complete street address, city, state, and zip code of the policyholder.

16.Enter the policyholder’s daytime telephone number, including area code. If the policyholder does not have a telephone number, please enter a message telephone number in the telephone number box and indicate “message.”

17.Indicate if the policyholder is court ordered to provide the insurance for the applicant.

18.Indicate if the policy is a Medicare HMO policy.

19.Indicate, by entering a checkmark in the appropriate box, how the insurance premiums are currently paid.

20.Enter the complete name and nine-digit Social Security number of other family members that are covered by Medi-Cal AND the health insurance policy listed in item 5.

21.Enter the full name of the policyholder’s employer.

22.Enter the telephone number of the policyholder’s employer, including area code.

23.Enter the full street address, city, state, and zip code of the policyholder’s employer.

24.Enter the name and type of illness for persons listed in item 18 who have a high-cost medical condition.

25.Sign and enter the date when you have completed this form.

Mail this form to: Department of Health Care Services, HIPP Program, MS 4719, PO Box 997422, Sacramento, CA 95899- 7422. If you have any questions about completing this form, call toll free 1-866-298-8443 (California only), 8:00 a.m.–5:00 p.m., Monday through Friday.

DHCS 6172 (12-07)

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