Forms: MC 100​​ 

• MC 171 (05/07) – Daim Ntawv Ceeb Toom Txog Kev Nkag Mus Rau Hauv Chaw Saib Xyuas Neeg Mob Mus Ntev ntawm Medi-Cal thiab Kev Tso Tawm Mus​​ 
• MC 174 (05/07) – Daim Ntawv Ceeb Toom Medi-Cal rau Cov Kws Muab Kev Pab Txog Kev Piav Qhia Txog Lub Luag Haujlwm (Eng/Sp)​​ 
  Alt: Spanish​​ 
• MC 175 I (05/07) – Sneede tawm tsam Kizer Cov Lus Nug Txog Kev Tshuaj Xyuas Nyiaj Tau Los​​ 
• MC 175-2 (05/07) – Sneede tawm tsam Kizer Kev Txiav Txim Siab Txog Tus Txheeb Ze Uas Muaj Lub Luag Haujlwm​​ 
• MC 175-3I (05/07) – Sneede v. Kizer Net Nonexempt Income Determination​​ 
• MC 175-3I.1 (05/07) – Sneede tawm tsam Kizer Net Nonexempt Income Determination-Continuation Sheet​​ 
• MC 175-3I.2A (05/07) – Tshooj 1931(b) Sneede tawm tsam Kizer Net Nonexempt Income Determination thiab Mini Budget Unit (MBU) Determination – Tus Neeg Thov​​ 
• MC 175-3I.2R (05/07) – Tshooj 1931(b) Sneede tawm tsam Kizer Net Nonexempt Income Determination thiab Mini Budget Unit (MBU) Determination – Tus Neeg Tau Txais​​ 
• MC 175-P (05/07) – Sneede tawm tsam Kizer Cov Lus Nug Txog Kev Tshuaj Xyuas Vaj Tse​​ 
• MC 175-3P (05/07) – Daim Ntawv Ua Haujlwm Txog Vaj Tse thiab Khoom ntawm Sneede vs. Kizer​​ 
• MC 175-4 (05/07) – Sneede tawm tsam Kizer Mini Budget Units Thiab:​​ 
• MC 175-5 (05/07) - Cov Kev Pabcuam Qib Kev Txom Nyem ntawm Tsoom Fwv Tebchaws (FPL) rau Cov Poj Niam Cev Xeeb Tub thiab Cov Menyuam Mos (Tsis suav nrog cov nyiaj tau los, 200 Feem pua); Cov Menyuam Yaus Muaj Hnub Nyoog 1 txog 5 (133 Feem pua); thiab Cov Menyuam Yaus Muaj Hnub Nyoog 6 txog 18 (100 Feem pua) (Rau Lub Nroog Siv Xwb)​​ 
• MC 175-6 (05/07) – Sneede v. Kizer Allocation from an SSI or IHSS Person​​ 
• MC 175-7 (05/07) – Sneede tawm tsam Kizer Daim Ntawv Teev Npe Ua Haujlwm thiab Tus Neeg Saib Xyuas rau Tus Txij Nkawm thiab/lossis Cov Menyuam hauv Tsev lossis Tus Neeg LTC (AFDC/MN/MI)Tsis Muaj Tus Txij Nkawm Hauv Zej Zog rau Cov Menyuam hauv Tsev​​ 
• MC 176-1 QMB/SLMB/QI (05/07) – Tus Neeg Tau Txais Medicare Uas Tsim Nyog (QMB)/Tus Neeg Tau Txais Medicare Uas Muaj Nyiaj Tsawg (SLMB)/Tus Neeg Tsim Nyog (QI) Daim Ntawv Ua Haujlwm Rau Txhua Tus Neeg Thov: Tus (cov) Neeg, Cov Niam Txiv, thiab Cov Menyuam (Tus Neeg LTC hauv MFBU)​​ 
• MC 176-2A QMB/SLMB/QI (09/08) – Tus Neeg Tau Txais Medicare Uas Tsim Nyog (QMB)/Tus Neeg Tau Txais Medicare Uas Muaj Nyiaj Tsawg (SLMB)/Tus Neeg Tsim Nyog (QI) Daim Ntawv Ua Haujlwm Tsim Nyog Tau Nyiaj, Cov Niam Txiv lossis Tus Neeg Thov uas Muaj Tus Txij Nkawm/Poj Niam Tsis Tsim Nyog, Muaj lossis Tsis Muaj Menyuam​​ 
• MC 176-2B QMB/SLMB/QI (05/07) – Tus Neeg Tau Txais Medicare Uas Tsim Nyog (QMB)/Tus Neeg Tau Txais Medicare Uas Muaj Nyiaj Tsawg (SLMB)/Tus Neeg Tsim Nyog (QI) Daim Ntawv Ua Haujlwm Tsim Nyog Tau Nyiaj, Menyuam Thov nrog lossis tsis muaj Niam Txiv Tsis Tsim Nyog​​ 
• MC 176 AD (10/20) – Aged and Disabled Federal Poverty Level Program Financial Eligibility Form​​ 
• MC 176 D (05/07) – Cov Kev Pabcuam Kho Mob Tshwj Xeeb ntawm Medi-Cal​​ 
• MC 176 EP (05/07) – Daim Ntawv Them Nyiaj Tsis Them Nqi​​ 
• MC 176 M (05/07) – Kev Txiav Txim Txog Feem Nqi – MFBUs Uas Tsis suav nrog Cov Neeg LTC​​ 
• MC 176 MA Tus Neeg Thov-Tus Tau Txais (05/07) - Tshooj 1931 Daim Ntawv Qhia Txog Nyiaj Txiag Rau Tus Neeg Thov/Tus Tau Txais: Rau Kev Txheeb Xyuas Cov Nyiaj Tau Los Tsis Zam Se thiab Tshooj 1931 Cov Nyiaj Tau Los Tsim Nyog Rau Cov Neeg Thov; Thiab Rau Cov Neeg Tau Txais Raws Li Lwm Txoj Kev Xaiv 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) – Kev Txiav Txim Txog Kev Sib Koom Nqi – MFBUs nrog LTC Cov Neeg suav nrog – LTC​​ 
• MC 176 P (05/07) – Daim Ntawv Ua Haujlwm Txog Kev Khaws Cia Vaj Tse​​ 
• MC 176 PA-1/PA-2 (05/07) – Daim Ntawv Ua Haujlwm/Kev Soj Ntsuam Vaj Tse Rau Cov Txij Nkawm Uas Nyob Hauv Tsev Kawm Ntawv (Eng/Sp)​​ 
  Alt: Spanish​​ 
• MC 176 P-A QMB/SLMB/QI (09/08) – Tus Neeg Tau Txais Medicare Uas Tsim Nyog (QMB)/Tus Neeg Tau Txais Medicare Uas Muaj Nyiaj Tsawg (SLMB)/Tus Neeg Tsim Nyog (QI) Daim Ntawv Ua Haujlwm Txog Vaj Tse, Neeg Laus​​ 
• MC 176 PA-A (05/07) – Daim Ntawv Thov Kev Ntsuam Xyuas Vaj Tse Medi-Cal​​ 
  Alt: Mev (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) – Lub Sijhawm Tsis Tsim Nyog Rau Daim Ntawv Ua Haujlwm Qib Kev Saib Xyuas Hauv Chaw Saib Xyuas Neeg Mob​​ 
• MC 176 PV (05/07) - Daim Ntawv Ua Haujlwm Txheeb Xyuas Tsheb rau Pawg 1931​​ 
• MC 176 QMB-3 (05/07) – Kev Xa Mus Rau Tus Neeg Tau Txais Medicare Uas Tsim Nyog (QMB)​​ 
• MC 176 QDWI (05/07) – Daim Ntawv Ua Haujlwm Txog Kev Tsim Nyog Tau Nyiaj Rau Cov Neeg Ua Haujlwm Xiam Oob Qhab (QDWI) - Cov Lus Qhia​​ 
• MC 176 QDWI-2 (05/07) – Qualified Disabled Working Individual (QDWI) Property Work Sheet​​ 
• MC 176 S (03/09) – Daim Ntawv Qhia Txog Xwm Txheej Medi-Cal (Lus Askiv)
  Lwm hom lus: Arabic, Armenian, Suav, Farsi, Hmoob, Cambodian, Kauslim, Lavxias, Mev, Tagalog, Nyab Laj​​ 
• MC 176 TMC (05/07) – Daim Ntawv Qhia Txog Kev Hloov Chaw Medi-Cal (TMC) Txhua Peb Hlis​​ 
  Alt: Spanish (10/08)​​ 
• MC 176 W (05/08) - Daim Ntawv Ua Haujlwm Faib Nyiaj/Kev Txiav Nyiaj Tshwj Xeeb​​ 
• MC 176 W.1 (05/07) – Stepparent Computation​​ 
• MC 179 (11/07) – Pawg Neeg Saib Xyuas Kev Pabcuam Txog Kev Tsis Taus​​ 
  Alt: Mev (01/08)​​ 
• MC 194 (07/12) – Social Security Administration Referral Notice​​ 
• MC 195 (07/17) – Daim Ntawv Xa Mus Rau Lub Nroog Rau Cov Neeg Thov MCIEP Uas Tau Txais SSI​​ 
• MC 196 (03/20) - Daim Ntawv Qhia Txog Kev Ceeb Toom Rau DHCS Txog MCIEP Cov Kev Hloov Pauv Hauv Qhov Xwm Txheej Rau Lub Nroog Kev Soj Ntsuam Kev Kho Mob lossis Cov Neeg Raug Tso Tawm Uas Muaj Kev Hlub​​ 

Rov qab mus rau Forms Index​​