Third Party Liability and Recovery Division (TPLRD) tuaj yeem ua daim ntawv thov them rov qab rau cov nyiaj them rov qab, cov nyiaj them tsis raug, thiab cov nyiaj them rov qab, ua los ntawm cov tuam txhab tuav pov hwm kev noj qab haus huv, cov kws kho mob, cov tswv cuab Medi-Cal, thiab cov kws lij choj. Lwm qhov kev them nyiaj suav nrog Kev Kho Mob Lub Cev thiab Cervical Cancer (BCCTP) thiab Health Insurance Premium Payment (HIPP) Program.​​ 

TPLRD’s payment process has changed. Both state and federal laws require that all reportable payments be identified and reported in the Payee Data Record (STD 204) form. This includes any state department that participates in a transaction resulting in a payment to any individual or entity that is not a governmental entity.​​ 

Txoj Cai Lij Choj:​​ 

• Lub Xeev Txoj Cai Tswjfwm Ntiag Tug Ntu 8422.19 thiab 8422.190​​ 
• Internal Revenue Code Tshooj 3402(t)​​ 

Pib txij Lub Ib Hlis Ntuj 1, 2012, TPLRD yuav xav kom tag nrho cov nyiaj them rau ib tus neeg lossis ib lub koom haum uas tsis yog tsoomfwv los ua kom tiav daim ntawv STD 204. Daim foos no yuav tsum ua kom tiav los ntawm tus neeg them nyiaj thiab yuav muab khaws cia rau hauv cov ntaub ntawv tsis pub lwm tus paub los ntawm Lub Tsev Haujlwm Saib Xyuas Kev Noj Qab Haus Huv (DHCS) ua ntej thov nyiaj rov qab lossis them nyiaj.​​ 

The form is available for download using this link: STD 204. Please carefully read the instructions provided on the second page of the STD 204 before completing the form. If an STD 204 is not properly completed as indicated in the instructions and filed with DHCS, your refund or payment request is subject to rejection. If the payee’s name and/or address changes, the payee must submit a new STD 204 with their current information.​​ 

The payee seeking payment could contact their TPLRD program representative for instructions on electronically sending a copy of the completed STD 204. The original signed copy of the completed STD 204 must be mailed to one of the following addresses below, or as instructed by your program representative.​​  

TPLRD Chaw Nyob Xa Ntawv:​​ 

Department of Health Care Services 
Third Party Liability and Recovery Division, MS 4720 
PO Thawv 997425
Sacramento, CA 95899-7425​​