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This version of the form is not currently in use and is provided for reference only. Download this version of
Form DHCS6172
for the current year.
Form DHCS6172 Health Insurance Premium Payment Application - California
What Is Form DHCS6172?
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 a DHCS6172 form?
A: The DHCS6172 form is an application for Health Insurance Premium Payment in California.
Q: Who can use the DHCS6172 form?
A: California residents who meet the eligibility criteria can use the DHCS6172 form to apply for health insurance premium payment.
Q: What is the purpose of the DHCS6172 form?
A: The purpose of the DHCS6172 form is to help eligible individuals in California to receive financial assistance for paying their health insurance premiums.
Q: What documents do I need to submit with the DHCS6172 form?
A: You may need to submit various documents along with the DHCS6172 form, such as proof of income, verification of current health insurance coverage, and other supporting documents.
Q: Is there a deadline for submitting the DHCS6172 form?
A: The deadline for submitting the DHCS6172 form may vary. It is important to check with the DHCS or your local DHCS office for the specific deadline.
Form Details:
- Released on September 1, 2015;
- The latest edition provided by the California Department of Health Care Services;
- Easy to use and ready to print;
- Available in Spanish;
- Quick to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of Form DHCS6172 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.
Download Form DHCS6172 Health Insurance Premium Payment Application - California
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