Form Dhcs 6172 PDF Details

Are you a provider or an individual who is trying to understand the DHCS 6172? Whether you are applying for a contract with your county's mental health plan, or compliantly completing the form for yourself, it can be confusing navigating all of the associated requirements. In this blog post, we'll break down what exactly Form DHCS 6172 means and how you can go about filling it out correctly. We'll also provide helpful tips on turning in your form so that everything is properly completed and documented. By the end of this article, you will have a good understanding of Form DHCS 6172 and be better prepared to get started!

Question	Answer
Form Name	Form Dhcs 6172
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	HIPP, 552a, LTC, medi

Form Preview Example

State of California—Health and Human Services Agency

Department of Health Care Services

HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM

APPLICATION

(please type or print clearly)

TELL US ABOUT THE PERSON WHO IS ON MEDI-CAL, HAS AN ILLNESS AND WANTS TO APPLY FOR THE HIPP PROGRAM

NAME (last, first, middle):

ADDRESS (street, city, state, zip code):

HOME TELEPHONE NUMBER:		WORK TELEPHONE NUMBER:			CELL TELEPHONE NUMBER:
(	)	(	)		(	)
MEDI-CAL BENEFICIARY IDENTIFICATION CARD (BIC) NUMBER:				E-MAIL	ADDRESS (optional):

TELL US ABOUT YOUR PRIVATE MEDICAL INSURANCE

INSURANCE COMPANY NAME:	INSURANCE COMPANY TELEPHONE NUMBER:
	(	)
INSURANCE COMPANY ADDRESS (street, city, state, zip code):

BILLING ADDRESS IF DIFFERENT (street, city, state, zip code):

POLICYHOLDER NAME (last, first, middle):	POLICYHOLDER DAYTIME TELEPHONE NUMBER:
	(	)

POLICYHOLDER ADDRESS (street, city, state, zip code):

POLICY NUMBER:			CURRENT PREMIUM AMOUNT:

GROUP NUMBER:			POLICY LAPSED ON:

HOW OFTEN IS POLICY PAID:
 Monthly	 Quarterly	 Other:_____________________________________________________

HOW ARE PREMIUMS CURRENTLY PAID (check one):
 Paid ENTIRELY by employer				 Paid by court-ordered absent parent
 Paid by policyholder through payroll deduction				 Paid by policyholder directly to insurance carrier
 Other:

TYPE OF COVERAGE YOUR MEDICAL INSURANCE PROVIDES (check all that apply):
 Hospital inpatient stays		 Doctor visits		 Vision	 Long-term care (LTC)
 Hospital outpatient (lab or therapy)		 Prescription drugs		 Dental	 Other:

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 (42 USC, 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.”

DHCS 6172 (Rev. 3/11)

Page 1 of 2

State of California—Health and Human Services Agency

Department of Health Care Services

HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM

APPLICATION

TELL US ABOUT THE PERSON YOU ARE APPLYING FOR AND ANY FAMILY MEMBERS ON THE SAME MEDICAL INSURANCE POLICY

TYPE OF

ENROLLED

FAMILY

NAME (last, first, middle):

CHECK ALL

COVERED BY

POLICY

IN (check all

MEDI-CAL BIC NO.

MEMBER

THAT APPLY:

POLICY?

(check one, if

that apply):

applicable):

 Medi-Cal

 Yes

 No

 Tricare

 Healthy

 Medicare

 MRMIP

SELF

Families

 Has an

 Policyholder

 Medicare

 AIM

illness

 Dependent

HMO

 Medi-Cal

 Yes

 No

 Tricare

 Healthy

FAMILY

 Medicare

 MRMIP

Families

MEMBER

 Has an

 Policyholder

 Medicare

 AIM

NO. 1

illness

 Dependent

HMO

 Spouse

 Parent

 Child

 Other

 Medi-Cal

 Yes

 No

 Tricare

 Healthy

FAMILY

 Medicare

 MRMIP

Families

MEMBER

 Has an

 Policyholder

 Medicare

 AIM

NO. 2

illness

 Dependent

HMO

 Spouse

 Parent

 Child

 Other

 Medi-Cal

 Yes

 No

 Tricare

 Healthy

FAMILY

 Medicare

 MRMIP

Families

MEMBER

 Has an

 Policyholder

 Medicare

 AIM

NO. 3

illness

 Dependent

HMO

 Spouse

 Parent

 Child

 Other

FOR ADDITIONAL FAMILY MEMBERS WITH MEDI-CAL, FILL OUT BELOW OR ATTACH INFORMATION ON A SEPARATE SHEET

DECLARATION: I declare under penalty of perjury under the laws of the State of California that the answers I have given in this application and the documents provided are true and correct to the best of my knowledge.

Name of Applicant (print):	Signature of Applicant/Guardian:	Date:

Name of Policyholder (print):	Signature of Policyholder:	Date:

DHCS 6172 (Rev. 3/11)

Page 2 of 2

How to Edit Form Dhcs 6172 Online for Free

With the help of the online PDF tool by FormsPal, you'll be able to fill out or modify MRMIP here. In order to make our editor better and easier to use, we consistently come up with new features, with our users' suggestions in mind. In case you are looking to get going, this is what you will need to do:

Step 1: Hit the "Get Form" button above on this page to open our editor.

Step 2: With our handy PDF editing tool, you may do more than just fill out blank fields. Express yourself and make your documents seem great with customized textual content incorporated, or modify the original input to perfection - all that comes with an ability to incorporate your own pictures and sign the file off.

It will be straightforward to complete the form using out helpful tutorial! This is what you have to do:

1. When filling out the MRMIP, make sure to include all of the important blank fields within the associated part. This will help to expedite the work, making it possible for your information to be processed quickly and appropriately.

2. After this part is filled out, proceed to type in the applicable information in these - POLICYHOLDER ADDRESS street city, HOW OFTEN IS POLICY PAID Monthly, Doctor visits, Quarterly, Other, CURRENT PREMIUM AMOUNT, POLICY LAPSED ON, Paid by courtordered absent, Vision Dental, Longterm care LTC Other, and IMPORTANT As a condition of.

3. In this part, take a look at NAME last first middle, CHECK ALL THAT APPLY, POLICY, check one if applicable Tricare, Yes No Policyholder Dependent, Yes No Policyholder Dependent, Tricare MRMIP Medicare, HMO, MediCal Medicare Has an illness, MediCal Medicare Has an illness, MediCal Medicare Has an illness, Yes No Policyholder Dependent, Tricare MRMIP Medicare, HMO, and Healthy AIM. Each one of these need to be filled out with utmost attention to detail.

CHECK ALL THAT APPLY, Yes No Policyholder Dependent, and Healthy AIM in california

4. Your next paragraph needs your input in the following areas: Declaration I declare under, Name of Applicant print, Signature of ApplicantGuardian, Name of Policyholder print, Signature of Policyholder, Date, and Date. Be sure to enter all required details to move forward.

california writing process described (portion 4)

Concerning Date and Signature of ApplicantGuardian, be certain you don't make any errors here. These two are considered the most important ones in this file.

Step 3: Revise all the information you have typed into the blanks and then click the "Done" button. Make a free trial subscription with us and get direct access to MRMIP - download, email, or edit inside your FormsPal cabinet. Here at FormsPal, we do our utmost to be sure that all of your details are stored protected.

Form Dhcs 6172 – Fill Out and Use This PDF

Form Dhcs 6172 PDF Details

Form Preview Example

How to Edit Form Dhcs 6172 Online for Free

Form Dhcs 6172 isn’t the one you’re looking for?

Form Dhcs 6172 – Fill Out and Use This PDF

Form Dhcs 6172 PDF Details

Form Preview Example

How to Edit Form Dhcs 6172 Online for Free

Form Dhcs 6172 isn’t the one you’re looking for?

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