Facility Review Scoring Summary Sheet (DHCS 4494) Facility Review Tool Scoring Instructions (DHCS 4493) Facility Staffing Data (DHCS 5050) 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 175-5, 05/07) Financial Card (MC 2213, 09/07) Financial Eligibility Work Sheet (Individual or Couple, Applicant With an Ineligible Spouse) (DHCS 7021, 05/07) Alt: Instructions Back to Forms Index
