State of California—Health and Human Services Agency Department of Health Care Services
RE: _________________________
Case name
_________________________
Case number
_________________________
Worker number
RESPONSIBILITIES OF PUBLIC GUARDIANS/CONSERVATORS
OR APPLICANT/BENEFICIARY REPRESENTATIVES
You have accepted the responsibility to act on behalf of ______________________________________________.
State law and regulation require you to report to the county welfare department any changes in the circumstances
of the applicant/beneficiary within ten calendar days following the date the change occurred. You must also
cooperate fully on behalf of the beneficiary in any review that may be required for quality control purposes.
Changes which must be reported within ten days include, but are not limited to:
1. A change in the beneficiary’s property, including community property.
2. A change in the beneficiary’s income.
3. Entitlement to Veteran’s Benefits or an increase in Veteran’s Benefits.
4. Changes in health insurance coverage including enrollment in available health insurance or the discontinuance
of health insurance.
5. A change in the beneficiary’s living arrangement, household members, or residence.
6. The death of the applicant/beneficiary.
7. A change in guardianship/conservator or representative status.
8. Any other change in circumstances which may affect eligibility or share of cost.
You are also required (pursuant to Probate Code, Section 700.1, and Welfare and Institutions Code,
Section 14009.5) to report the death of the beneficiary within 90 days of the date of death to:
DHCS—Third Party Liability Branch
Estate Recovery Unit
MS 4720
P.O. Box 997425
Sacramento, CA 95899-7425
Refer to “IMPORTANT INFORMATION FOR PERSONS REQUESTING MEDI-CAL” (MC 219) for a more complete
list of your reporting responsibilities.
I hereby state, under penalty of perjury, that the information on this form has been reviewed by me and that I fully
understand my responsibilities as the guardian, conservator or representative of
Name of Beneficiary
Signature of Guardian/Conservator or Representative Date
Address of Guardian/Conservator or Representative Telephone number of Guardian/Conservator or Representative
Original—Case File Copy—Guardian/Conservator or Representative
DHCS 7068 (06/07)
