استمارات MC 200 الخاصة بقسم أهلية ميدي-كال MC 200
العودة إلى الصفحة الرئيسية لنماذج وزارة التنمية الاقتصادية
يتم سرد نماذج قسم أهلية ميدي-كال (MCED) بالترتيب الأبجدي أدناه حسب رقم النموذج وقد تتضمن لغات بديلة إذا كانت متاحة. يمكن تعبئة وطباعة النماذج بصيغة PDF عبر الإنترنت وطباعتها على نسخة ورقية للتوقيع عليها وإرسالها بالبريد أو تقديمها شخصيًا إلى موظف الأهلية لمعالجتها.
تحديث!
سيتم الآن إتاحة جميع نماذج الأهلية الافتراضية للنساء الحوامل على موقع مزود الخدمة الخاص بنا للنموذج (النماذج) التالية
MMC 263-SR، وMc 264، وMc 265، وMc 266، وMc 267، وMc 283، وMc 285، وMc 286، وMc 286 & Mc 286
نماذج MC 200.
- MC 209 (05/12) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
- MC 210 A (09/07) – Supplement to Statement of Facts for Retroactive Coverage/Restoration
- البديل: الإسبانية
- MC 210 B (05/07) – Supplement to Statement of Facts (PICKLE Eligibility/Determination)
- البديل: الإسبانية
- MC 210 PA (05/07) – Property Assessment Statement of Facts
- البديل: الإسبانية
- MC 210 RV (10/20) – Medi-Cal Annual Redetermination
- MC 210 S-C (05/07) – Additional Children (Supplement to the Medi-Cal Statement of Facts, MC 210) (Eng/Sp)
- MC 210 S-E (05/07) – Student Educational Expenses (Supplement to Medi-Cal Statement of Facts, MC 210)
- البديل: الإسبانية
- MC 210 S-I (09/08) – Income In-Kind/Housing Verification (Supplement to the MC 210 Statement of Facts) (Eng/Sp)
- MC 210 S-W (05/07) – Vocational and Work History
- البديل: الإسبانية
- MC 212 (05/07) – Medi-Cal Residency Declaration (Eng/Sp)
- MC 214 (05/07) – Important Information About Residency
- البديل: الإسبانية
- MC 215 (05/07) – Request for Withdrawal and/or Waiver of Ten-Day Advance Notice
- Alt: Spanish (10/07)
- MC 216 (10/20) – Pre-Populated Renewal Form
- MC 217 (10/20) – Pre-Populated Renewal Form
- MC 219 (11/15) – Important Information for Persons Requesting Medi-Cal (Large Print, Eng)
- MC 220 8pt (06/08) – Authorization for Release of Information
- البديل: الإسبانية
- MC 220 14pt (04/08) – Authorization for Release of Information (Large Print)
- البديل: الإسبانية
- MC 221 LA (02/14) – Disability Determination and Transmittal (Los Angeles)
- MC 222 LA (02/14) – DDSD Pending Information Update (Los Angeles)
- MC 223 (10/09) – Applicant’s Supplemental Statement of Facts for Medi-Cal
- MC 223 C (06/11) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only- Under Age 18 (MC 223C) Instructions
- MC 224 A (06/07) – Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage
- MC 224 A-S (05/07) – Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage
- MC 224 B (06/07) – Medi-Cal Potential Overpayment Reporting Work Sheet – Property Total Ineligibility or Ineligibility For A Specific Level of Services
- MC 224 B-S (05/07) – Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet – Property Total Ineligibility or Ineligibility For A Specific level of Services
- MC 239 DRA-6 (02/10) – Information Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
- MC 250 (05/07) – Application and Statement of Facts for Child Not Living with a Parent or Relative and for Whom a Public Agency is Assuming Some Financial Responsibility
- MC 250 A (12/14) – Application for Medi-Cal for Former Foster Care Youth
- البديل: الإسبانية
- MC 262 (06/07) – Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
- البديل: الإسبانية
- MC 272 (05/07) – SGA Work Sheet
- MC 273 (05/07) – Work Activity Report
- البديل: الإسبانية
- MC 274 TB (05/07) – Medi-Cal Tuberculosis Program Application
- البديل: الإسبانية
- MC 278 TB (05/07) – Tuberculosis (TB) Program Property Worksheet Adult
- MC 279 TB (05/07) – Tuberculosis (TB) Program Property Worksheet Child
- MC 280 TB (05/07) – Tuberculosis (TB) Program Financial Eligibility Worksheet – Eligible Child with Ineligible Parent or Parent(s)
- MC 281 TB (05/07) – Tuberculosis (TB) Program Income Eligibility Worksheet
- MC 282 TB (05/07) – Tuberculosis (TB) Program Income Eligibility Worksheet