Form Dhcs 7068 - California Responsibilities Of Public Guardians/conservators Or Applicant/beneficiary Representatives - Health And Human Services Agency

Download a blank fillable Form Dhcs 7068 - California Responsibilities Of Public Guardians/conservators Or Applicant/beneficiary Representatives - Health And Human Services Agency in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form Dhcs 7068 - California Responsibilities Of Public Guardians/conservators Or Applicant/beneficiary Representatives - Health And Human Services Agency with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Department of Health Care Services
State of California—Health and Human Services Agency
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)

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Form Dhcs 5080 - California C-9 Personal Rights Substance Use Disorder Treatment Facilities - Health And Human Services Agency Form Dhcs 5080 - California C-9 Personal Rights Substance Use Disorder Treatment Facilities - Health And Human Services Agency Legal
Form Dhcs 6237 - California Request To Access Protected Health Information By Parent, Guardian Or Personal Representative - Health And Human Services Agency Form Dhcs 6237 - California Request To Access Protected Health Information By Parent, Guardian Or Personal Representative - Health And Human Services Agency Legal
Form Dhcs 0006 - California Proof Of Citizenship Or Identity Needed (armenian) - Health And Human Services Agency Form Dhcs 0006 - California Proof Of Citizenship Or Identity Needed (armenian) - Health And Human Services Agency Legal
Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (tagalog) - Health And Human Services Agency Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (tagalog) - Health And Human Services Agency Legal
Form Dhcs 0006 - California Proof Of Citizenship Or Identity Needed (arabic) - Health And Human Services Agency Form Dhcs 0006 - California Proof Of Citizenship Or Identity Needed (arabic) - Health And Human Services Agency Legal
Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (spanish) - Health And Human Services Agency Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (spanish) - Health And Human Services Agency Legal
Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (farsi) - Health And Human Services Agency Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (farsi) - Health And Human Services Agency Legal
Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (laotian) - Health And Human Services Agency Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (laotian) - Health And Human Services Agency Legal
Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (korean) - Health And Human Services Agency Form Dhcs 0005 - California Receipt Of Citizenship Or Identity Documents (korean) - Health And Human Services Agency Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (spanish) - Health And Human Services Agency Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (spanish) - Health And Human Services Agency Legal

Related Categories

Parent category: Legal
Download
Go