Otlicp 2026

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The document is a refund or waiver request form from the California Department of Health Care Services, intended for counties to submit requests for premium refunds or waivers due to reasons such as untimely discontinuance or incorrect aid codes. It includes fields for personal and county information, the reason for the request, and verification by an eligibility worker.

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Click ‘Get Form’ to open the otlicp in the editor.
Begin by entering the date at the top of the form. This is essential for processing your request.
Fill in your county name and contact information, including phone and fax numbers, to ensure proper communication.
Specify the refund details by providing the name and CIN (Client Identification Number) of the individual related to this request.
Select a reason for the refund or waiver from the provided options, ensuring you include any necessary documentation if applicable.
Indicate the month(s) and year for which you are requesting a refund or waiver effective date.
Complete the EW (Eligibility Worker) section by entering their name and code, followed by obtaining their signature to verify accuracy.

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