Get Potential Third Party Liability Notification - Department Of Health ...

This guide provides clear and concise instructions on how to fill out the Potential Third Party Liability Notification form from the Department of Health online. Follow these steps to ensure that your submission is accurate and complete.

Follow the steps to fill out the form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by indicating whether you have used or will use Medi-Cal for your injury or illness by selecting 'Yes' or 'No'.
3. Next, answer if you have filed or will file a lawsuit or insurance claim, again selecting 'Yes' or 'No'.
4. If you answered 'Yes' to either of the previous questions, provide details of where the injury or illness occurred by selecting the appropriate location, such as 'Home', 'Work', 'School', 'Motor vehicle', 'On someone else’s property', or 'Other'. Additionally, fill in the case name, date of injury or illness, and address information.
5. Provide your Social Security number and mailing address, including city, state, and ZIP code.
6. Fill in your telephone number and provide the name and date of birth of the injured person, along with the corresponding county code.
7. Indicate if you have filed or will file a lawsuit by selecting 'Yes' or 'No'. If 'Yes', provide details including attorney name, telephone number, and mailing address.
8. If there is any other insurance covering you or anyone else for this injury or illness, select 'Yes' or 'No'. If 'Yes', provide the name of the insurance company, telephone number, mailing address, and claim/policy number.
9. For work-related injuries, indicate if you have filed an application for Workers’ Compensation benefits and provide additional employer and claim details if applicable.
10. Once all sections are completed, review your information for accuracy, then save changes, and download or print the form for submission.

Complete your documents online to ensure a timely and efficient submission process.