Dhcs 6168-2025

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The document is a notification form from the Department of Health Care Services in California, designed to collect information regarding potential third-party liability for individuals who have used Medi-Cal for injuries or illnesses. It includes questions about the use of Medi-Cal, any lawsuits or insurance claims filed, details about the injury location, personal information of the injured party, and insurance coverage related to the incident.

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Click ‘Get Form’ to open the dhcs 6168 in the editor.
Begin by entering the date at the top of the form. This is essential for processing your notification.
In the 'Potential Third Party Liability Notification' section, answer whether you have used Medi-Cal for your injury or illness by selecting 'Yes' or 'No'.
If you answered 'Yes' to either question, specify where the injury occurred by checking the appropriate box (Home, Work, School, etc.).
Fill in your personal details including case name, date of injury, address, and social security number in the designated fields.
Indicate if you have filed a lawsuit by selecting 'Yes' or 'No', and provide attorney details if applicable.
Lastly, complete any insurance information if applicable and ensure all fields are filled accurately before submission.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

Do I have to report a settlement to Medi-Cal?

If you file a personal injury lawsuit as a Medi-Cal member, you must notify the California Department of Health Care Services (DHCS) within 30 days of filing the suit. You are also required to notify DHCS as soon as you get your settlement and when your medical treatment ends.

What is the DHCS definition of homelessness?

An individual or family who lacks adequate nighttime residence; An individual or family with a primary residence that is a public or private place not designed for or ordinarily used for habitation; An individual or family living in a shelter; An individual exiting an institution into homelessness; An

What do you have to report to Medi-Cal?

You must give income and tax filing status information for everyone who is in your family and is on your tax return. You also may need to give information about your property. You do not have to file taxes to qualify for Medi-Cal.

Will I lose Medicaid if I get a settlement?

If you receive a lump sum settlement, it may be considered as income or resources, which could impact your Medicaid eligibility. If you remain eligible for Medicaid, the settlement funds may impact the benefits awarded.

What is DHCS presumptive eligibility?

Hospital Presumptive Eligibility allows certain health care providers to approve temporary health coverage for eligible applicants using an electronic application. Hospital Presumptive Eligibility determinations are based on the applicants self-attestation of facts and no other forms of proof are required.

What is third party liability in Medi-Cal billing?

Third Party Liability (TPL) refers to the legal obligation of third parties (for example, certain individuals, entities, insurers, or programs) to pay part or all of the expenditures for medical assistance furnished under a Medicaid state plan.

Can Medi-Cal take my settlement?

Medi-Cal cant take more than 50% of your settlement. If you fail to notify the government that youre filing a lawsuit, the DHCS can take legal action against you to obtain Medi-Cal reimbursements.

Is a Medi-Cal settlement taxable income?

If you are awarded a settlement for injuries or illness and did not take an itemized tax deduction for medical costs related to that injury or sickness, your settlement is not taxable. You do not have to include your injury case settlement as part of your income on tax documents.

Dhcs 6168-2025

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