DHCS will not seek reimbursement if the Medi-Cal member is survived by a child who is blind or disabled within the meaning of the federal Social Security Act on the date of the Estate Recovery claim. However, if a surviving child does not have verification of disability or blindness from the Social Security Administration, a request for disability determination may be submitted to DHCS.
The following documents must be filled out and submitted within 60 days of the claim to the Estate Recovery Section at the address listed below. Please note that by submitting this information you are NOT applying for Social Security Disability benefits. The application is used for Estate Recovery purposes only.
MC 223 - Applicant's Supplemental Statement of Facts for Medi-Cal (PDF)
MC 220 - Authorization for Release of Information (PDF)
DHCS 6249 - Appointment of Representative - Estate Recovery (PDF)
Department of Health Care Services
Estate Recovery Section, MS 4720
PO Box 997425
Sacramento, CA 95899-7425
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