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Get Dhcs 6168 Pdf Form

Tems OR Date: WC Recovery Program 660 J Street, Suite 270 Sacramento, CA 95814 Mail: File: Original Copy POTENTIAL THIRD PARTY LIABILITY NOTIFICATION 1. Have you used, or will you use, Medi-Cal for your injury or illness? .......................................................... Yes 2. Have you filed, or will you file, a lawsuit or insurance claim?..................................................................... Yes No No If you answered Yes to one or both of the.

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