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This form is used to confirm the distribution of CHDP policy information to providers and to document the date of distribution of Provider Information Notices in the CHDP program.
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How to fill out dhcs 4504 - dhcs
How to fill out DHCS 4504
01
Obtain the DHCS 4504 form from the official website or your healthcare provider.
02
Fill in your personal information at the top of the form, such as your name, address, and contact details.
03
Provide your Medi-Cal number, if applicable, ensuring it is accurate.
04
Complete the health questionnaire section honestly, detailing your current health status and any relevant medical history.
05
Indicate any income information as required to determine eligibility or assistance levels.
06
Review your information for accuracy and completeness.
07
Sign and date the form at the designated area.
08
Submit the completed DHCS 4504 form through the specified method, whether online, by mail, or in person.
Who needs DHCS 4504?
01
Individuals seeking to apply for or renew Medi-Cal benefits.
02
Patients needing to provide health information for program eligibility assessment.
03
Anyone required to report changes in their health status or income related to Medi-Cal.
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What is DHCS 4504?
DHCS 4504 is a form used by the California Department of Health Care Services to collect information regarding the eligibility and enrollment of Medi-Cal beneficiaries.
Who is required to file DHCS 4504?
Providers and organizations responsible for managing Medi-Cal beneficiary information are required to file DHCS 4504.
How to fill out DHCS 4504?
To fill out DHCS 4504, complete the required fields with accurate beneficiary data, including personal information, eligibility status, and any necessary attachments as specified by the form's instructions.
What is the purpose of DHCS 4504?
The purpose of DHCS 4504 is to ensure proper eligibility verification, track enrollment changes, and maintain accurate records for Medi-Cal beneficiaries.
What information must be reported on DHCS 4504?
DHCS 4504 requires reporting of personal details such as the beneficiary's name, date of birth, Medi-Cal number, eligibility category, and other relevant information necessary for maintaining their health coverage.
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