Form Dhcs 7068 PDF Details

Navigating the responsibilities and obligations when acting on behalf of another, especially in the realm of health and welfare, is a significant undertaking. The Department of Health Care Services (DHCS) 7068 form, introduced by the State of California's Health and Human Services Agency, serves as a critical tool in this navigation, outlining the duties of public guardians, conservators, or representatives of applicants and beneficiaries. This form not only identifies the various changes in a beneficiary’s circumstances that must be reported within ten calendar days—ranging from adjustments in income or property to shifts in living arrangements or health insurance coverage—but also underscores the importance of timely communication concerning the death of a beneficiary. Emphasized within this paperwork is the statutory requirement for reporting to the county welfare department and cooperating with quality control reviews. Furthermore, the form underscores the legal implications of these responsibilities by requiring a declaration under penalty of perjury, thereby reinforcing the gravity and accountability entailed in acting on behalf of another. By understanding and adhering to the stipulations laid down in the DHCS 7068 form, guardians, conservators, or representatives can ensure compliance with state laws and regulations, securing the welfare and rights of those they represent.

QuestionAnswer
Form NameForm Dhcs 7068
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesdhs 7068 english form, dhcs 7068 pdf, medical form dhcs 7068, dhcs 7068

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State of California—Health and Human ServicesAgencyDepartment of Health CARE Services

RE: _________________________

Case name

_________________________

Case number

_________________________

Worker number

RESPONSIBILITIES OF PUBLIC GUARDIANS/CONSERVATORS

ORAPPLICANT/BENEFICIARYREPRESENTATIVES

You have accepted the responsibility to act on behalf of ______________________________________________.

State law and regulation require you to report to the county welfare department any changes in the circumstances of the applicant/beneficiary within ten calendar days following the date the change occurred. You must also cooperate fully on behalf of the beneficiary in any review that may be required for quality control purposes.

Changes which must be reported within ten days include, but are not limited to:

1.Achange in the beneficiary’s property, including community property.

2.Achange in the beneficiary’s income.

3.Entitlement to Veteran’s Benefits or an increase in Veteran’s Benefits.

4.Changes in health insurance coverage including enrollment in available health insurance or the discontinuance of health insurance.

5.Achange in the beneficiary’s living arrangement, household members, or residence.

6.The death of the applicant/beneficiary.

7.Achange in guardianship/conservator or representative status.

8.Any other change in circumstances which may affect eligibility or share of cost.

You are also required (pursuant to Probate Code, Section 700.1, and Welfare and Institutions Code, Section 14009.5) to report the death of the beneficiary within 90 days of the date of death to:

DHCS—Third Party Liability Branch

Estate Recovery Unit

MS 4720

P.O. Box 997425

Sacramento, CA 95899-7425

Refer to “IMPORTANT INFORMATION FOR PERSONS REQUESTING MEDI-CAL” (MC 219) for a more complete list of your reporting responsibilities.

I hereby state, under penalty of perjury, that the information on this form has been reviewed by me and that I fully understand my responsibilities as the guardian, conservator or representative of

 

 

Name of Beneficiary

 

 

 

 

Signature of Guardian/Conservator or Representative

 

Date

 

 

 

Address of Guardian/Conservator or Representative

 

Telephone number of Guardian/Conservator or Representative

 

 

 

 

 

 

 

 

 

 

Original—CaseFile

Copy—Guardian/ConservatororRepresentative

DHCS 7068 (06/07)

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