​​​Online Forms 

The Department of Health Care Services (DHCS), Third Party Liability and Recovery Division (TPLRD) is required by federal and state law to recover funds for Medi-Cal paid services related to a liable third party action in which a settlement, judgment, award or claim occurs.

Whether you are a Medi-Cal beneficiary, a legal representative, an insurer or other referring party, the forms below will help you submit proper notification to DHCS, thereby satisfying the reporting requirements pursuant to Welfare and Institutions (W&I) Code Section 14124.73, et seq.

Complete the appropriate form in its entirety, review for accuracy, and submit only once. Multiple submissions may result in delayed processing. Allow 30 days for DHCS to send a letter confirming receipt of the notification. If the injured party is Medi-Cal eligible, the letter will detail DHCS’ recovery rights and lien process. A lien will be provided after DHCS receives the following information:

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

Per W&I Code Section 14124.73(c) the beneficiary’s valid Medi-Cal ID number must be provided to satisfy reporting requirements.  The Medi-Cal ID number can be found on the beneficiary’s ID card as indicated in the examples below. The number required within the online forms is comprised of the first 9 characters of the ID beginning with “9”, followed by 7 additional numbers, and ending with a letter.

Old BIC with ID number circledNew BIC with ID number circled 

DHCS Tax ID Number: 68-0317191 


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Personal Injury (PI)                         

PI - Step 1
Personal Injury Notification (New Case)
PI - Step 2
Case Update or Additional Documentation (PI)       
PI - Step 3
Pay online   ​

​Workers Compensation (WC)         

WC - Step 1
Workers' Compensation Notification (New Case)​
WC - Step 2
Case Update or Additional Documentation (WC)
WC - Step 3
​Pay online 

​Miscellaneous Forms                     

Payee Data Record
Letter of Guarantee (Form 4204)

​Managed Care                                

Managed Care Single Member Submission
Managed Care Multi-Member Form​

Last modified date: 4/25/2022 8:31 AM