Formularios: MC 100
Formularios: MC 100
- MC 171 (05/07) – Medi-Cal Long-Term Care Facility Admission and Discharge Notification
- MC 174 (05/07) – Medi-Cal Notice to Providers Clarification of Liability (Eng/Sp)
Alt: Español - MC 175 I (05/07) – Sneede v. Kizer Income Screening Questions
- MC 175-2 (05/07) – Sneede v. Kizer Responsible Relative Determination
- MC 175-3I (05/07) – Sneede v. Kizer Net Nonexempt Income Determination
- MC 175-3I.1 (05/07) – Sneede v. Kizer Net Nonexempt Income Determination-Continuation Sheet
- MC 175-3I.2A (05/07) – Section 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Determination – Applicant
- MC 175-3I.2R (05/07) – Section 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Determination – Recipient
- MC 175-P (05/07) – Sneede v. Kizer Property Screening Questions
- MC 175-3P (05/07) – Sneede v. Kizer Property Work Sheet
- MC 175-4 (05/07) – Sneede v. Kizer Mini Budget Units And:
- MC 175-5 (05/07) – Federal Poverty Level (FPL) Programs for Pregnant Women and Infants (Income Disregard, 200 Percent); Children Ages 1 through 5 (133 Percent); and Children Ages 6 through 18 (100 Percent) (For County Use Only)
- MC 175-6 (05/07) – Sneede v. Kizer Allocation from an SSI or IHSS Person
- MC 175-7 (05/07) – Sneede v. Kizer Allocation Work Sheet Board and Care Person to Spouse and/or Children at Home or LTC Person (AFDC/MN/MI)With No Community Spouse to Children at Home
- MC 176-1 QMB/SLMB/QI (05/07) – Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI)Eligibility Work Sheet For All Applicants: Individual(s), Couple(s), and Child(ren) (LTC Individual in MFBU)
- MC 176-2A QMB/SLMB/QI (09/08) – Hoja de cálculo de elegibilidad de ingresos para beneficiarios calificados de Medicare (QMB), beneficiarios específicos de Medicare de bajos ingresos (SLMB) e individuos calificados (QI), parejas o solicitantes con cónyuges no elegibles, con o sin hijos.
- MC 176-2B QMB/SLMB/QI (05/07) – Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI)Income Eligibility Work Sheet, Child Applying with or without Ineligible Parent(s)
- MC 176 AD (10/20) – Aged and Disabled Federal Poverty Level Program Financial Eligibility Form
- MC 176 D (05/07) – Programde Tratamiento Especial Medi-Cal
- MC 176 EP (05/07) – Formulario de Pago Exento
- MC 176 M (05/07) – Share of Cost Determination – MFBUs Which Do Not Include LTC Persons
- MC 176 MA Applicant-Recipient (05/07) – Section 1931 Applicant/Recipient Budget Form: For Determining Net Non-Exempt Income and Section 1931 Income Eligibility for Applicants; And for Recipients Under Alternative B
- MC 176 MA Recipient (05/07) – Section 1931 Recipient Budget Form: For Determining Net Non-Exempt Income and Section 1931 Income Eligibility for Recipients Under Alternative A
- MC 176 M-LTC (11/07) – Share of Cost Determination – MFBUs with LTC Persons Included – LTC
- MC 176 P (05/07) – Property Reserve Worksheet
- MC 176 PA-1/PA-2 (05/07) – Property Worksheet/Assessment for Institutionalized Spouses (Eng/Sp)
Alt: Español - MC 176 P-A QMB/SLMB/QI (09/08) – Beneficiario calificado de Medicare (QMB)/Beneficiario de Medicare de bajos ingresos especificado (SLMB)/Individuo calificado (QI) Hoja de trabajo de propiedad, Adulto
- MC 176 PA-A (05/07) – Solicitud de evaluación de propiedad de Medi-Cal
Alt: Spanish (01/09) - MC 176 P-C QMB/SLMB/QI (05/07) – Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI)Property Work Sheet, Child
- MC 176 PI (07/22) – Period of Ineligibility for Nursing Facility Level-of-Care Work Sheet
- MC 176 PV (05/07) – Hoja de cálculo de Determinación de Vehículos para el Grupo 1931
- MC 176 QMB-3 (05/07) – Remisión de beneficiario calificado de Medicare (QMB)
- MC 176 QDWI (05/07) – Qualified Disabled Working Individual (QDWI) Income Eligibility Work Sheet-Instructions
- MC 176 QDWI-2 (05/07) – Qualified Disabled Working Individual (QDWI) Property Work Sheet
- MC 176 S (03/09) – Reporte de estado de Medi-Cal (inglés)
Alt: árabe, armenio, chino, farsi, hmong, camboyano, coreano, ruso, español, tagalo, vietnamita - MC 176 TMC (05/07) – Transitional Medi-Cal (TMC) Quarterly Status Report
Alt: Spanish (10/08) - MC 176 W (05/08) – Hoja de cálculo de asignación/deducción especial
- MC 176 W.1 (05/07) – Stepparent Computation
- MC 179 (11/07) – División de Servicio de Determinación de Discapacidad
Alternativa: Español (01/08) - MC 194 (07/12) – Social Security Administration Referral Notice
- MC 195 (17/07) – Transmisión del condado para solicitantes de MCIEP que reciben SSI
- MC 196 (03/20) – Transmittal Form for Notifying DHCS of MCIEP Changes in Status for County Medical Probation or Compassionate Release Inmates