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Form DHCS4204 Commitment to Pay Reimbursable Medi-Cal Lien Amount - California
What Is Form DHCS4204?
This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the DHCS4204 form?
A: The DHCS4204 form is a Commitment to Pay Reimbursable Medi-Cal Lien Amount form in California.
Q: What is the purpose of the DHCS4204 form?
A: The purpose of the DHCS4204 form is to commit to paying the reimbursable Medi-Cal lien amount.
Q: Who needs to fill out the DHCS4204 form?
A: The DHCS4204 form needs to be filled out by individuals or entities who are responsible for paying a reimbursable Medi-Cal lien amount.
Q: Is the DHCS4204 form specific to California?
A: Yes, the DHCS4204 form is specific to California.
Q: What happens after I submit the DHCS4204 form?
A: After you submit the DHCS4204 form, the California Department of Health Care Services (DHCS) will review your commitment to pay the reimbursable Medi-Cal lien amount.
Q: Are there any fees associated with the DHCS4204 form?
A: No, there are no fees associated with the DHCS4204 form.
Q: Can I appeal a decision made based on the DHCS4204 form?
A: Yes, you can appeal a decision made based on the DHCS4204 form by following the appropriate appeals process in California.
Form Details:
- Released on May 1, 2018;
- The latest edition provided by the California Department of Health Care Services;
- Easy to use and ready to print;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a fillable version of Form DHCS4204 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.
