Form DHCS9113 "Appointment of Representative" - California

What Is Form DHCS9113?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2015;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHCS9113 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form DHCS9113 "Appointment of Representative" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
Health Insurance Premium Payment (HIPP) Program
APPOINTMENT OF REPRESENTATIVE
(or additional contact) – (optional)
NAME (last, first, middle):
RELATIONSHIP/ORGANIZATION:
Additional contact only
Authorized to act on my behalf
Both
ADDRESS (street, city, state, zip code):
DAYTIME TELEPHONE NUMBER:
E-M AIL ADDRESS (optional):
NAME (last, first, middle):
RELATIONSHIP/ORGANIZATION:
Additional contact only
Authorized to act on my behalf
ADDRESS (street, city, state, zip code):
DAYTIME TELEPHONE NUMBER:
E-M AIL ADDRESS (optional):
Signature of Applicant or Guardian
Date
SIGNATURE AND DECLARATION (required)
IMPORTANT: As a condition of eligibility, all Medi-Cal beneficiaries shall assign rights to medical insurance,
support, or other third-party payments to the Medi-Cal program and shall cooperate with the California
Department of Health Care Services (DHCS) in obtaining medical support or payments. The assignment of
rights to benefits is effective only for services paid for by the Medi-Cal program. This Assignment allows
DHCS to recover funds from health insurance companies when the Medi-Cal program pays for medical
services which should have been billed to other health coverage. Please note that in order to comply with the
Federal Privacy Act (42 USC, Section 552a), your Social Security Number and any information you provide
may be disclosed to insurance companies, employers, health care service providers and county agencies to
determine the extent of available health insurance. Under Welfare and Institutions Code, Section 14100.2, any
submitted information is considered confidential and disclosed only as necessary for Medi-Cal program
administration purposes.
Declaration: I declare under penalty of perjury under the laws of the State of California that the answers I have
given in this application and the documents provided are true and correct to the best of my knowledge.
Name of Applicant (print):
Signature of Applicant/Guardian:
Date:
Name of Policyholder (print):
Signature of Policyholder:
Date:
DHCS 9113 (Rev. 09/15)
State of California—Health and Human Services Agency
Department of Health Care Services
Health Insurance Premium Payment (HIPP) Program
APPOINTMENT OF REPRESENTATIVE
(or additional contact) – (optional)
NAME (last, first, middle):
RELATIONSHIP/ORGANIZATION:
Additional contact only
Authorized to act on my behalf
Both
ADDRESS (street, city, state, zip code):
DAYTIME TELEPHONE NUMBER:
E-M AIL ADDRESS (optional):
NAME (last, first, middle):
RELATIONSHIP/ORGANIZATION:
Additional contact only
Authorized to act on my behalf
ADDRESS (street, city, state, zip code):
DAYTIME TELEPHONE NUMBER:
E-M AIL ADDRESS (optional):
Signature of Applicant or Guardian
Date
SIGNATURE AND DECLARATION (required)
IMPORTANT: As a condition of eligibility, all Medi-Cal beneficiaries shall assign rights to medical insurance,
support, or other third-party payments to the Medi-Cal program and shall cooperate with the California
Department of Health Care Services (DHCS) in obtaining medical support or payments. The assignment of
rights to benefits is effective only for services paid for by the Medi-Cal program. This Assignment allows
DHCS to recover funds from health insurance companies when the Medi-Cal program pays for medical
services which should have been billed to other health coverage. Please note that in order to comply with the
Federal Privacy Act (42 USC, Section 552a), your Social Security Number and any information you provide
may be disclosed to insurance companies, employers, health care service providers and county agencies to
determine the extent of available health insurance. Under Welfare and Institutions Code, Section 14100.2, any
submitted information is considered confidential and disclosed only as necessary for Medi-Cal program
administration purposes.
Declaration: I declare under penalty of perjury under the laws of the State of California that the answers I have
given in this application and the documents provided are true and correct to the best of my knowledge.
Name of Applicant (print):
Signature of Applicant/Guardian:
Date:
Name of Policyholder (print):
Signature of Policyholder:
Date:
DHCS 9113 (Rev. 09/15)