Webplacement of the county code and aid code on the form above Box 5. Explanation of Form Items (continued Item Description 6 Pending. Leave this box blank 7 Sex and Age. Use the capital “M” for male, or “F” for female. Enter age of the recipient in the Age box. 8 Date of Birth. Enter the recipient’s date of birth in a six-digit format ... http://appdir.dhcs.ca.gov/bhis/Pages/Approver.aspx

Personal Injury, Third Party Liability, and Worker’s …

Web1. Opening up a case file To inform Medi-Cal of the existence of a case, go to: http://www.dhcs.ca.gov/services/Pages/TPLRD_PersonalInjuryUnit.aspx. Click on the Online Forms link at the bottom of the page, then the Attorney Referral link and provide the requested information. It will then take up to 120 days for Medi-Cal to respond in writing. 2. WebJun 10, 2024 · Forms Enrollment Family PACT Provider Agreement ( DHCS 4469) Form Family PACT Practitioner Agreement ( DHCS 4470 )* Form * The DHCS 4470 is not required to be completed by Primary Care Clinics, Affiliate Primary Care Clinics, RHCs, IHCs, and government providers. Client Client Eligibility Certification (CEC) (DHCS 4461) … binary world ag

Every Woman Counts (EWC) Manuals, Forms and Worksheets - Medi-Cal

http://www.partnershiphp.org/About/Documents/LegalUnit/PersonalInjury_ThirdPartyLitigation.pdf WebThe DHCS Personal Injury Program has imposed a lien on my settlement, Can I get a reduction? Yes, there are three sections of the Welfare and Institutions (W&I) Code that allow for a reduction of a lien. DHCS’s recovery is limited to the amount derived from applying Sections 14124.72, 14124.76, and 14124.78 whichever is less. WebBeneficiary Information: Full Name Medicare Number Gender and Date of Birth Complete Address and Phone Number Case Information: Date of Injury/Accident, or Date of First Exposure, Ingestion or Implant Description of Alleged Injury, Illness or Harm Type of Claim (Liability Insurance, No-Fault Insurance, Workers’ Compensation) cyriaque boughareb