Notice To Department Of Health Care Services {RI-PR036}

RI-PR036 - NOTICE TO DEPARTMENT OF HEALTH CARE SERVICES. This form is used to notify the California Department of Health Care Services (DHCS) about the death of an individual who received, or whose predeceased spouse or partner may have received, health care benefits under Medi-Cal. It is required under California Probate Code §§ 215, 9202(a), and 19202 to inform DHCS of potential estate recovery claims. The form provides the decedent's details, the notifier's information, and attaches necessary documents, such as death certificates. It includes proof of service to confirm the notice was mailed to DHCS. Approved for Optional Use. Probate Code §§ 215, 9202(a), 19202. www.FormsWorkflow.com