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Online Forms

Thank you for visiting the Medi-Cal Personal Injury Program on-line forms page. These forms have been designed to assist law firms, insurance companies, and other referral sources to submit notice to the Department of Health Care Services pursuant to Welfare and Institutions Code Section 14124.73, et seq. 

 

Submitting information about an action or claim using the forms below satisfies reporting requirements under State law. Please complete the appropriate form in its entirety, review for accuracy, and submit only once. Multiple submissions may result in delayed processing. After submission, you will receive the initial Notice of Lien by mail. A lien will be provided after we receive the following information:

  • Final date of treatment related to the injury with a Medi-Cal provider, AND/OR
  • Date of settlement

 

The lien with an itemized list of injury-related services will be sent to the Medi-Cal member or personal representative and the liable third party.

  

Alert:

The forms below require a valid Medi-Cal ID number for submission. This number can be found on the beneficiary Medi-Cal ID card. To the right is a sample image of a Medi-Cal ID card. The number required is comprised of the first 9 characters of the ID starting with the number “9”, followed by 7 additional number, and ending with a letter.


Sample Card.png

       
 

 

DHCS Tax ID Number: 68-0317191

 

Personal Injury (PI)                               Workers' Compensation (WC)

Last modified on: 1/13/2017 4:00 PM