Fillable CHANGE OF STATUSLIENS (Department of Health Care Services)

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CHANGE OF STATUSLIENS (Department of Health Care Services)

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The CHANGE OF STATUSLIENS (Department of Health Care Services) form is 1 page long and contains:

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  • 16 check-boxes
  • 64 other fields

Country of origin: US
File type: PDF

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State of California—Health and Human Services Agency Department of Health Care Services
CHANGE OF STATUS–LIENS
Name of Beneficiary Medi-Cal Identification Number Social Security Number
__ __ – __ __ – __ __ __ __ __ __ __ – __ – __ __
ࠈ Discharged from long-term care and returned home on ____________________________
ࠈ Requested a county level review on ___________________________________________
ࠈ Requested a state hearing/rehearing on ________________________________________
ࠈ County level review decision issued on _________________________________________
ࠈ State hearing/rehearing decision issued on ______________________________________
Lien may be recorded ࠈ Yes ࠈ No
Beneficiary’s Address (number, street) City State ZIP Code
ࠈ Other information/changes:
Eligibility Worker signature Eligibility Worker number Telephone number
( )
Date
Mail to: Department of Health Care Services
Third Party Liability and Recovery Division
Estate Recovery Section
MS 4720
P.O. Box 997425
Sacramento, CA 95899-7425
Telephone number: (916) 650-0490
DHCS 7013 (06/07)
State of California—Health and Human Services Agency Department of Health Care Services
CHANGE OF STATUS–LIENS
Name of Beneficiary Medi-Cal Identification Number Social Security Number
__ __ – __ __ – __ __ __ __ __ __ __ – __ – __ __
ࠈ Discharged from long-term care and returned home on ____________________________
ࠈ Requested a county level review on ___________________________________________
ࠈ Requested a state hearing/rehearing on ________________________________________
ࠈ County level review decision issued on _________________________________________
ࠈ State hearing/rehearing decision issued on ______________________________________
Lien may be recorded ࠈ Yes ࠈ No
Beneficiary’s Address (number, street) City State ZIP Code
ࠈ Other information/changes:
Eligibility Worker signature Eligibility Worker number Telephone number
( )
Date
Mail to: Department of Health Care Services
Third Party Liability and Recovery Division
Estate Recovery Section
MS 4720
P.O. Box 997425
Sacramento, CA 95899-7425
Telephone number: (916) 650-0490
DHCS 7013 (06/07)
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State of California—Health and Human Services Agency Department of Health Care Services
INSTRUCTIONS FOR DHCS 7013
CHANGE OF STATUS–LIENS
The form is completed in duplicate; the original sent to DHCS Recovery, the copy retained in the
case record.
1. Enter beneficiary’s full name, Medi-Cal ID number, and Social Security number.
2. Check box and enter requested information.
3. Eligibility Worker signs and dates form.
DHCS 7013 (06/07)
State of California—Health and Human Services Agency Department of Health Care Services
INSTRUCTIONS FOR DHCS 7013
CHANGE OF STATUS–LIENS
The form is completed in duplicate; the original sent to DHCS Recovery, the copy retained in the
case record.
1. Enter beneficiary’s full name, Medi-Cal ID number, and Social Security number.
2. Check box and enter requested information.
3. Eligibility Worker signs and dates form.
DHCS 7013 (06/07)
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CHANGE OF STATUSLIENS (Department of Health Care Services)

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Completed 23 November 2020

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