Get Dhcs 6168

Filling out the Dhcs 6168 form is essential for notifying the Department of Health Care Services about potential third-party liability related to your injury or illness. This guide provides a step-by-step approach to help users complete the form easily and accurately.

Follow the steps to complete your Dhcs 6168 form online

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin with the date field: Enter the current date on which you are filling out the form.
3. In the potential third-party liability notification section, indicate whether you have used or will use Medi-Cal for your injury or illness by selecting ‘Yes’ or ‘No’.
4. Next, specify if you have filed, or will file, a lawsuit or insurance claim by marking the corresponding option.
5. If you answered ‘Yes’ to either question, complete the details about the injury or illness. Choose from options such as home, work, school, motor vehicle, someone else's property, or other, and fill in any additional information required, including the case name and the date of the injury or illness.
6. Provide your social security number, mailing address, and contact details to ensure proper identification.
7. Fill in the name and date of birth for the injured person(s) along with any relevant county code.
8. Indicate if you have filed a lawsuit using the designated options. If yes, provide attorney details including their name, telephone number, and mailing address.
9. State whether you have insurance coverage other than Medi-Cal or Medicare for this injury or illness. If yes, include the insurance company’s details, telephone number, mailing address, and claim information.
10. Lastly, complete the relevant fields regarding workers’ compensation claims and provide details about your employer at the time of the accident.
11. Review the entire form for accuracy. Once completed, you can save the changes, download, print, or share the form as needed.

Complete your Dhcs 6168 form online today to ensure timely processing of your case.