INSTRUCTIONS
Property Lien Referral (DHCS 7014)
A. For each beneficiary owning real property that may be liened in accordance with Section 50428, the county shall complete
the Property Lien Referral and forward it to the Department of Health Care Services’ Estate Recovery Section within 30
days of the date the List Property For Sale—Persons in LTC (MC 239 W) notice is sent to the applicant/beneficiary.
B. The following describes the information which is to be provided on the Property Lien Referral. Items 1 through 13 must be
completed by the Eligibility Worker. Items 15 through 18 are for DHCS’s use only.
COUNTY USE ONLY
1. Name of the county. This must be the county of responsibility regardless of where the property is located.
2. Name of the beneficiary. This must be the name that appears on the SAWS 1. If the beneficiary’s name is different on
the deed to the property, indicate with “AKA.”
3. a. Name of institution or facility.
b. Current address of beneficiary.
4. Responsible party, if other than the beneficiary. Include his/her name, address, and telephone number.
5. Medi-Cal identification (ID) number. This must be the current entire case number. If any changes are made to this
number, it must be reported to the Estate Recovery Section using the Change of Status—Liens form (DHCS 7013).
The new number should be noted in the other information/change section of the form.
6. Social Security number. This must be verified in accordance with Section 50168. If any changes are made to this
number, it must be reported to the Estate Recovery Section using the Change of Status—Liens form (DHCS 7013).
The new number should be noted in the other information/change section of the form.
7. Medicare number or other health insurance information.
8. Property address. Included in this section would be the county and the state, if other than California, where the
property is located. If the property is in California, only the county is necessary. If the location is outside the State,
both the county and state are required.
9. Other legal owner(s). Identify individual(s) sharing title with the beneficiary.
10. Fair market value (FMV). The real estate agency listing contract with the FMV appraisal shown must be attached to
the Property Lien Referral. The appraisal requirements specified in Section 50425 must be followed.
11. Enter the county assessor’s parcel number from a tax statement, deed, etc. Furnish a copy of the deed.
12. The date the Notice of Action—List Property For Sale (MC 239 W) was sent. A lien will be recorded by the Estate
Recovery Section upon receipt of the Property Lien Referral.
13. Enter the Eligibility Worker’s name and telephone number in case additional information is needed.
14. Enter the Eligibility Supervisor’s signature, showing that the form is complete and contains accurate information.
STATE USE ONLY
15.–16. The form will be signed by the Estate Recovery Section and a copy mailed to the county within ten days of
receipt, showing that the form was complete and all documents were received.
17. If information is missing that would prevent Department of Health Care Services from filing a lien, the Estate Recovery
Section will indicate by checking the appropriate box and returning the form and all attached documents to the county.
18. Contact the Estate Recovery Section, (916) 650-0490, if there are any questions regarding this form.
DHCS 7014 (06/07)
