​Forms By Name - S

• ​"Safe Arms for Newborns" Medical Questionnaire (MC 356, 05/07)
   Alt: Spanish
• Screening Work Sheet (DHCS 7020, 06/07)
• Screening Worksheet Disabled Widow(er) Checklist (DW) Ages 50 to 64 (DHCS 7089, 05/07)
• SD/MC Monthly Claim for Reimbursement - Quality Assurance/Utilization Review (QA/UR) Cost  (MC 1982 C, 07/12)
• SD/MC Quarterly Claim for Reimbursement - Administrative Cost (MC 1982 B, 07/12)
  Alt: MC 1982 B (Excel)  
• SD/MC Quarterly Claim for Reimbursement - Medi-Cal Administrative Activities (MAA) (MC 1982 D, 07/12)
  Alt: MC 1982 D - (Excel)
• SD/MC Quarterly Claim for Reimbursement - Treatment Cost (MC 1982 A, 07/12)
• 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 Applicant-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 MA Recipient, 05/07)
• Section 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Determination - Applicant (MC 175-3I.2A, 05/07)
• Section 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Determination - Recipient (MC 175-3I.2R, 05/07)
• SGA Work Sheet (MC 272, 05/07)
• Share of Cost Determination - MFBUs Which Do Not Include LTC Persons (MC 176 M, 05/07)
• Share of Cost Determination - MFBUs with LTC Persons Included - LTC (MC 176 M-LTC, 11/07)
• Share-of-Cost Medi-Cal Provider Letter (MC 1054, 6/07)
• Sneede v. Kizer Allocation from an SSI or IHSS Person (MC 175-6, 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 175-7, 05/07)
• Sneede v. Kizer Income Screening Questions (MC 175 I, 05/07)
• Sneede v. Kizer Mini Budget Units And:(MC 175-4, 05/07)
• Sneede v. Kizer Net Nonexempt Income Determination (MC 175-3I, 05/07)
• Sneede v. Kizer Net Nonexempt Income Determination-Continuation Sheet (MC 175,-31.1, 05/07)
• Sneede v. Kizer Property Screening Questions (MC 175-P, 05/07)
• Sneede v. Kizer Property Work Sheet (MC 175-3P, 05/07)
• Sneede v. Kizer Responsible Relative Determination (MC 175-2, 05/07)
• Sneede v. Kizer Section 1931(b) Property Work Sheet (MC 324, 05/07)
• Social Security Administration Referral Notice (MC 194, 07/12)
• Sole Proprietor Application (DHCS 5111) 
• CCS Special Care center Directory Update Form  (DHCS 4507, 01/08) 
• SSI/SSP Income Test Work sheet For The 250 Percent Working Disabled Program - Adults (MC 338 A, 05/07)
• SSI/SSP Property Test Worksheet For The 250 Percent Working Disabled Program - Adults and Child Applicants (MC 338 C, 05/07)
• Staff Health Questionnaire (DHCS 5105)
• Statement of Citizenship, Alienage, and Immigration Status (MC 13, 12/09)
• Statement of Living Arrangements, In-Kind Support, and Maintenance (DHCS 7044, 12/08)
• Stepparent Computation (MC 176 W.1, 05/07)
• Student Educational Expenses (Supplement to the Medi-Cal Statement of Facts, MC 210) (MC 210 S-E, 05/07)  
  Alt: Spanish
• Successor Liability with Joint and Several Liability Agreement (DHCS 6217, 02/08)
• Supplement to Statement of Facts (Pickle Eligibility/ Determination) (MC 210 B, 05/07)
  Alt: Spanish
• Supplement to Statement of Facts for Retroactive Coverage/Restoration (MC 210 A, 09/07)
  Alt: Spanish
• Supplemental Application Request for Additional Services (DHCS 5255)
• Supplemental 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 Income or Other Health Coverage (MC 224 A-S, 05/07)
• Supplemental Security Income (SSI) Methodology Adult Income Eligibility Worksheet (MC 326 A, 05/07)
• Supplemental Security Income (SSI) Methodology Income Worksheet - Eligible Child with Ineligible Parent or Parent(s) (MC 326 C, 05/07)
• Supplemental Security Income (SSI) Program Property Worksheet Adult (MC 327 A, 05/07)
• Supplemental Security Income (SSI) Program Property Worksheet Child (MC 327 C, 05/07)
• Supplemental Statement of Facts for Medi-Cal Child Applicant Only- Under Age 18 (MC 223C)
  Instructions (MC 223 C, 06/11)
  Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese

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