Form Dhcs 7013 - California Change Of Status Liens - Health And Human Services Agency
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1
2Department of Health Care Services
State of California—Health and Human Services Agency
CHANGE OF STATUS–LIENS
Name of Beneficiary
Medi-Cal Identification Number
Social Security Number
__ __ – __ __ – __ __ __ __ __ __ __ – __ – __ __
Discharged from long-term care and returned home on ____________________________
Requested a county level review on ___________________________________________
Requested a state hearing/rehearing on ________________________________________
County level review decision issued on _________________________________________
State hearing/rehearing decision issued on ______________________________________
Lien may be recorded
Yes
No
Beneficiary’s Address (number, street)
ZIP Code
City
State
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)
Department of Health Care Services
State of California—Health and Human Services Agency
CHANGE OF STATUS–LIENS
Name of Beneficiary
Medi-Cal Identification Number
Social Security Number
__ __ – __ __ – __ __ __ __ __ __ __ – __ – __ __
Discharged from long-term care and returned home on ____________________________
Requested a county level review on ___________________________________________
Requested a state hearing/rehearing on ________________________________________
County level review decision issued on _________________________________________
State hearing/rehearing decision issued on ______________________________________
Lien may be recorded
Yes
No
Beneficiary’s Address (number, street)
ZIP Code
City
State
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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