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See Section 19D of the Medi-Cal Eligibility Procedures Manual. If the applicant/beneficiary is entitled to zero share of cost Medi-Cal under regular eligibility rules no waiver is required. Please send a copy of the Notice of Action to the Regional Center when the determination is completed. White County copy DHCS 7096 05/07 Yellow Regional Center Copy.
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Who needs dhcs 7096:
01
Individuals who are seeking assistance with healthcare coverage.
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Those who meet the eligibility criteria for government assistance programs related to healthcare.
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Individuals who are unable to afford the cost of medical care and require financial aid.
It is important to note that the specific eligibility requirements can vary depending on the state and program for which the dhcs 7096 form is intended. Therefore, it is advisable to review the instructions and guidelines provided with the form to determine if you meet the necessary criteria for submission.
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What is dhcs 7096?
DHCS 7096 is a form used by the California Department of Health Care Services to request an administrative review of a decision made by the department.
Who is required to file dhcs 7096?
The DHCS 7096 form is required to be completed and submitted by any provider who is requesting an exemption from Medi-Cal's usual billing requirements for a particular service or procedure.
How to fill out dhcs 7096?
1. On the first page, enter your name, date of birth, address, and contact information.
2. On the second page, enter the name and address of the health care provider that you are seeking services from, as well as the date of service.
3. On the third page, enter the diagnosis codes and any other relevant information related to the service being requested.
4. On the fourth page, enter the requested services and the cost for the services.
5. On the fifth page, enter your insurance information and any other relevant information related to the service being requested.
6. On the sixth page, enter any additional information or questions regarding the service being requested.
7. On the seventh page, sign and date the form.
8. Return the form to the health care provider.
What is the purpose of dhcs 7096?
The DHCS 7096 form is used by health care providers to collect information from Medi-Cal applicants and recipients. This form is used to verify eligibility and to determine the type of Medi-Cal coverage that is available to the applicant or recipient.
What information must be reported on dhcs 7096?
The California Department of Health Care Services' Form 7096 collects information related to the completion of a Medi-Cal Eligibility Determination. The form must include the following information:
1. Applicant's name
2. Applicant's birthdate
3. Applicant's Social Security Number
4. Applicant's current address
5. Applicant's citizenship/immigration status
6. Applicant's income
7. Applicant's assets
8. Applicant's medical expenses
9. Applicant's current Medi-Cal eligibility status
10. Applicant's Medi-Cal eligibility renewal date
11. Applicant's Medi-Cal ID number
12. Applicant's Person Number
13. County of residence
14. Signature of the person completing the form
What is the penalty for the late filing of dhcs 7096?
The California Department of Health Care Services (DHCS) does not impose a penalty for late filing of the DHCS 7096 form. However, the DHCS may take other action against a provider, such as delaying or denying reimbursement for services, if the provider does not comply with the reporting requirements.
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