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State of California Department of Health Care Services (Department of Health Care Services)

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State of California
Health and Human Services Agency
Department of Health Care Services
Request for Medi-Cal Expenses Subject to Estate Recovery
Medi-Cal members and their authorized representatives have the right to request a record of Medi-
Cal expenses subject to an Estate Recovery claim. Please note payment information may change
due to adjustment in rates, pending claims from providers, or additional services rendered. The
Department of Health Care Services (DHCS) would only have a claim for certain services provided
on or after a recipient’s 55
th
birthday, unless an individual is/was permanently institutionalized.
The requestor must pay a $5 fee to cover the costs associated with this request. Please make
checks payable to the Department of Health Care Services.
To verify your identity, DHCS requires you to send a copy of your photo identification card, such as a
California Driver’s License or Department of Motor Vehicles Identification Card. To verify an address
different than the one indicated on your identification, provide a utility bill or other proof of address. If
you do not have access to a California Driver’s License, Department of Motor Vehicles Identification
Card, or other acceptable document, your signature must be notarized by a licensed notary public. If
you are requesting information on behalf of a Medi-Cal member, DHCS requires written proof that you
are legally authorized to act on behalf of the Medi-Cal member.
Mail this completed form, check, and supporting documentation to:
Department of Health Care Services
Estate Recovery Section, DHCS 4017
P.O. Box 997425, MS 4720
Sacramento, CA 95899-7425
DO NOT COMPLETE THIS FORM IF:
• The Medi-Cal member has a personal injury case and Medi-Cal has paid for related
services. Please call (916) 445-9891.
• You are requesting access to records on behalf of a deceased Medi-Cal member (you may have
received an Estate Recovery Questionnaire in the mail). Please call(916) 650-0590.
• The Medi-Cal member is involved in a worker’s compensation case in which Medi-Cal has
paid for services. Please call (916) 445-9891.
• This information has already been requested within the current calendar year.
FORM INSTRUCTIONS:
• Are you requesting your own payment information? If yes, complete Sections 1, 3, and 4, and
attach proof of your identity and address verification.
• Are you legally authorized to act on behalf of the Medi-Cal member? If yes, complete Sections 1,
2, 3, and 4, and attach proof of your identity and legalauthorization.
• If you do not have legal authority to act on behalf of the Medi-Cal member, please have the Medi-
Cal member complete Section 1, 3, and 4, attach proof of his or her identity, and direct the
payment records be sent to you in Section 4.
Warning: any attempt to falsely gain access to protected health information is subject to legal penalties
DHCS 4017 (Rev.06/19) Page 1 of 4
SECTION 1: MEDI-CAL MEMBER INFORMATION
(The person who is the subject of the records)
LAST NAME FIRST NAME MIDDLE
INITIAL
ADDRESS CITY/STATE ZIP CODE
State of California
Health and Human Services Agency
Department of Health Care Services
MEDI-CAL ID NUMBER
TELEPHONE NUMBER
DATE OF
BIRTH
SECTION 2: AUTHORIZED REPRESENTATIVE INFORMATION
You must attach written documentation to verify your legal authority to act on behalf of the
Medi
-Cal member. Examples of documents that prove authorization to request payment records
include: legal documents appointing you as guardian or con
servator of the individual whose records
you seek; financial, medical, or durable power of attorney signed by the individual whose records you
seek. If you do not have
written documentation of your legal authority, please have the Medi-Cal
member complete
the form and request the records be sent to you in Section 4.
OF THE MEDI-CAL MEMBER:
Guardian Conservator
Financial Power of Attorney Medical Power of Attorney
Durable Power of Attorney Other, please describe
LAST NAME FIRST NAME MIDDLE INITIAL
ADDRESS CITY/STATE ZIP CODE
TELEPHONE NUMBER
INDICATE YOUR LEGAL AUTHORITY TO REQUEST RECORDS
Warning: any attempt to falsely gain access to protected health information is subject to legal penalties
DHCS 4017 (Rev.06/19) Page 2 of 4
State of California
Health and Human Services Agency
NOTARIZED BY ON (DATE)
Department of Health Care Services
SECTION 3: IDENTIFYING INFORMATION
If you are the Medi-Cal member or authorized representative, please provide a copy of your
identification and address verification, then sign the certification.
Please attach a copy of one of the following documents:
California Driver’s License
California DMV Identification Card
Birth Certificate
Other Identification Document (e.g. passport, school ID, etc.)
Please attach a document that verifies your address. If the address on your Driver’s License,
DMV ID card, birth certificate, or other identification document matches the address in
Section 4, this is not required.
TYPE: (For example, a utility bill or phone bill)
CERTIFICATION:
I declare under penalty of perjury that the information on this form is true and correct.
MEDI-CAL MEMBER/REPRESENTATIVE SIGNATURE
DATE
NOTE: If you do not attach a copy of your identification, your signature must be notarized.
NOTARY PUBLIC NUMBER
UNOFFICIAL UNLESS STAMPED BY NOTARY PUBLIC
Warning: any attempt to falsely gain access to protected health information is subject to legal penalties
DHCS 4017 (Rev.06/19) Page 3 of 4
State of California
Health and Human Services Agency
Warning: any attempt to falsely gain access to protected health information is subject to legal penalties
DHCS 4017 (Rev.06/19) Page 4 of 4
Department of Health Care Services
SECTION 4: WHERE WOULD YOU LIKE TO OBTAIN YOUR PAYMENT RECORDS?
Please mail me a copy of the requested records at the address in Section 1 (Medi-Cal member
address).
Please mail a copy of the requested records to the address in Section 2 (authorized
representative address).
Please mail a copy of the requested records to the person of my choosing indicatedbelow.*
*NOTE: Any person may be named below. The Department will not send records to photocopy
services.
NAME
FIRM (IF APPLICABLE)
ADDRESS
CITY, STATE, ZIP CODE
TELEPHONE NUMBER
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State of California Department of Health Care Services (Department of Health Care Services)

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Completed 30 July 2020

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