Form Dhcs 9113 PDF Details

In navigating the complexities of healthcare benefits, the State of California provides critical support mechanisms through various forms, one of which is the Department of Health Care Services (DHCS) Form 9113. This form is a gateway for individuals receiving Medi-Cal benefits to appoint representatives who can act on their behalf concerning the Health Insurance Premium Payment (HIPP) Program. It offers options to either appoint someone as an additional contact or authorize them to act fully on the applicant's behalf, ensuring that beneficiaries have the necessary support in managing their healthcare needs. Beyond the appointment of representatives, this form serves a broader function as it embodies the agreement of Medi-Cal beneficiaries to assign their rights to potential medical insurance, support, or other third-party payments to the Medi-Cal program. This assignment is vital for the program's ability to reclaim funds from health insurance companies for services that Medi-Cal has paid but should have been billed to other coverage. With a stringent emphasis on confidentiality in alignment with the Federal Privacy Act and Welfare and Institutions Code, the DHCS 9113 form also underscores the importance of accurate and truthful disclosure of information by applicants, reinforcing the legal underpinnings that structure Medi-Cal’s interactions with beneficiaries and their designated representatives.

QuestionAnswer
Form NameForm Dhcs 9113
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesDHCS 9113 (Appointment of Representative) ADA 3 11 where do i mail a dhcss form9113

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State of California—Health and Human Services Agency

Department of Health Care Services

Health Insurance Premium Payment (HIPP) Program

APPOINTMENT OF REPRESENTATIVE

(or additional contact) – (optional)

I HEREBY APPOINT THE FOLLOWING INDIVIDUAL(S) TO ACT ON MY BEHALF IN THE MANNER CHECKED BELOW:

NAME (last, first, middle):

RELATIONSHIP/ORGANIZATION:

Additional contact only

Authorized to act on my behalf Both

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

DAYTIME TELEPHONE NUMBER:

E-MAIL ADDRESS (optional):

 

 

(

)

 

 

 

 

 

 

NAME (last, first, middle):

RELATIONSHIP/ORGANIZATION:

 

 

 

 

 

Additional contact only

 

 

 

 

Authorized to act on my behalf

 

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

DAYTIME TELEPHONE NUMBER:

E-MAIL ADDRESS (optional):

()

__________________________________________________

______________________

Signature of Applicant or Guardian

Date

SIGNATURE AND DECLARATION (required)

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 (DHCS) in obtaining medical support or payments. The assignment of rights to benefits is effective only for services paid for by the Medi-Cal program. This Assignment allows DHCS to recover funds from health insurance companies when the Medi-Cal program pays for medical services which should have been billed to other health 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 disclosed to 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.

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 9113 (Rev. 3/11)

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Filling out this document usually requires care for details. Ensure that all necessary blank fields are filled out accurately.

1. The Form Dhcs 9113 requires specific details to be inserted. Ensure that the following fields are filled out:

Step no. 1 of submitting Form Dhcs 9113

2. Once this array of fields is completed, you have to add the needed specifics in ADDRESS street city state zip code, Name of Applicant print, Signature of ApplicantGuardian, Name of Policyholder print, Signature of Policyholder, Date, Date, and DHCS Rev in order to progress further.

Date, Name of Applicant print, and DHCS Rev in Form Dhcs 9113

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