मेडी-काल एलिजिबिलिटी डिवीजन एमसी 200 फॉर्म
MCED फ़ॉर्म के मुख्य पृष्ठ पर वापस जाएं
मेडी-काल एलिजिबिलिटी डिवीजन (MCED) फॉर्म संख्या के अनुसार वर्णानुक्रम में नीचे सूचीबद्ध हैं और यदि उपलब्ध हो तो वैकल्पिक भाषाएं शामिल हो सकती हैं। PDF फ़िल और प्रिंट फ़ॉर्म ऑनलाइन भरे जा सकते हैं और हार्डकॉपी में प्रिंट किए जा सकते हैं, जिन पर हस्ताक्षर किए जा सकते हैं और उन्हें मेल किया जा सकता है या प्रोसेसिंग के लिए पात्रता कार्यकर्ता को व्यक्तिगत रूप से सबमिट किया जा सकता है।
अपडेट करें!
गर्भवती महिलाओं के लिए सभी अनुमानित पात्रता प्रपत्र अब हमारी प्रदाता वेबसाइट पर निम्नलिखित प्रपत्रों के लिए उपलब्ध कराए जाएंगे:
एमसी 263-एसआर, एमसी 264, एमसी 265, एमसी 266, एमसी 267, एमसी 283, एमसी 285, & एमसी 286
एमसी 200 फॉर्म:
- MC 209 (05/12) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
- ऑल्ट: अरबी, अर्मेनियाई, चीनी, फारसी, हमोंग, कम्बोडियन, कोरियाई, स्पैनिश, तागालोग, वियतनामी
- MC 210 A (09/07) – Supplement to Statement of Facts for Retroactive Coverage/Restoration
- ऑल्ट: स्पैनिश
- MC 210 B (05/07) – Supplement to Statement of Facts (PICKLE Eligibility/Determination)
- ऑल्ट: स्पैनिश
- MC 210 PA (05/07) – Property Assessment Statement of Facts
- ऑल्ट: स्पैनिश
- 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)
- ऑल्ट: स्पैनिश
- 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
- ऑल्ट: स्पैनिश
- MC 212 (05/07) – Medi-Cal Residency Declaration (Eng/Sp)
- MC 214 (05/07) – Important Information About Residency
- ऑल्ट: स्पैनिश
- 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
- ऑल्ट: स्पैनिश
- MC 220 14pt (04/08) – Authorization for Release of Information (Large Print)
- ऑल्ट: स्पैनिश
- 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
- ऑल्ट: स्पैनिश
- MC 262 (06/07) – Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
- ऑल्ट: स्पैनिश
- MC 272 (05/07) – SGA Work Sheet
- MC 273 (05/07) – Work Activity Report
- ऑल्ट: स्पैनिश
- MC 274 TB (05/07) – Medi-Cal Tuberculosis Program Application
- ऑल्ट: स्पैनिश
- 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