Get Dhcs 6168

Filling out the Dhcs 6168 form is an important process for those who have used Medi-Cal for an injury or illness. This guide will support you with clear instructions and steps to effectively complete the form online.

Follow the steps to complete your Dhcs 6168 form online.

1. Click ‘Get Form’ button to access the Dhcs 6168 form and open it in your online editor.
2. Begin by answering whether you have used or will use Medi-Cal for your injury or illness. Select 'Yes' or 'No' as applicable.
3. If you answered 'Yes' to the previous question, indicate whether you have filed or will file a lawsuit or insurance claim. Again, choose 'Yes' or 'No'.
4. In this section, provide details about the injury or illness. Specify where it occurred: at home, school, someone else's property, workplace, motor vehicle, or other.
5. Enter your full name (first, middle, last), the date of the injury or illness, and your complete address, including city, state, and ZIP code.
6. Provide your social security number and mailing address if different from the residential address. Include your phone number as well.
7. List any person(s) injured, their names, and their dates of birth.
8. Indicate if you have initiated or will initiate a lawsuit. Choose 'Yes' or 'No' and provide your attorney's name, phone number, and address if applicable.
9. Answer whether you have any insurance coverage apart from Medi-Cal or Medicare, such as automobile or health insurance. If yes, provide the insurance company's information, including phone number and claim policy number.
10. If applicable, state if you have filed a workers' compensation claim and provide your employer's information at the time of the accident.
11. Review all the completed information for accuracy. When satisfied, you can save changes, download, print, or share the form as needed.

Complete your Dhcs 6168 form online today to ensure proper processing of your claims.