Form Dhcs 9113 PDF Details

Are you looking for guidance on how to complete the Form DHCS 9113? Trying to figure out what it is and how it fits into your health care plan can be overwhelming, so this blog post was created as a helpful resource. In this article, we will go over what form DHCS 9113 is used for, why you need it and when, as well as process steps and tips to assist you in completing the form accurately and quickly. By following these easy instructions outlined here in this blog post, you will have all of the information needed to get started with your very own streamlined workflow!

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

Form Preview Example

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)

How to Edit Form Dhcs 9113 Online for Free

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Step 1: Just click the "Get Form Button" above on this page to start up our pdf editor. This way, you'll find all that is necessary to work with your file.

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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

It is possible to make errors while filling out the Date, consequently be sure to look again prior to deciding to submit it.

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