Dhcs 6168-2026

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The document is a notification form from the Department of Health Care Services in California, intended for individuals who have used Medi-Cal for injuries or illnesses and may have potential third-party liability. It collects information regarding the injury, any lawsuits or insurance claims filed, and details about the injured person and their insurance coverage.

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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 tracking your submission.
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.
If applicable, provide information about any lawsuits filed and include your attorney's contact details.
Indicate if there is any insurance covering you for this injury and provide relevant insurance company details.
Finally, review all entered information for accuracy before saving or submitting your completed form.

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