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​Request for Medi-Cal Expenses Subject to Estate Recovery

DHCS 4017

Members or their legally authorized representatives may request a record of Medi-Cal payments that may be subject to Estate Recovery in the future.  To obtain this information you must submit, “Request for Medi-Cal Expenses Subject to Estate Recovery,” (Form DHCS 4017) (PDF) with the required documentation and $5 processing fee to the address listed on the form.

You should not complete a DHCS 4017 if:

  • You have a personal injury case and Medi-Cal has paid for related services; click here.
  • 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); click here.
  • You are involved in a worker’s compensation case, in which Medi-Cal has paid for services; please call Health Management Systems, Inc. at 916-760-5100.

 

Only services received on or after a member’s 55th birthday are subject to estate recovery (unless the member was permanently institutionalized).  The Department will not seek collection during the lifetime of your surviving spouse or registered domestic partner.  Payment information may change due to adjustment in rates, pending claims from providers, or additional services rendered.  For fee-for-service claims report questions, please contact the provider.        

 

The expense information you receive is not a bill.  In fact, Federal and state law prohibit collection during your lifetime.  For more information on situations where Estate Recovery may or may not apply; click here.

 

Return to Estate Recovery.

Last modified on: 1/11/2017 12:58 PM