Daim Ntawv MC 100 ntawm Pawg Neeg Saib Xyuas Kev Tsim Nyog ntawm Medi-Cal
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Medi-Cal Daim Ntawv Qhia Txog Kev Tsim Nyog Muaj Peev Xwm muaj npe nyob rau hauv cov tsiaj ntawv hauv qab no los ntawm tus lej daim ntawv thiab tej zaum yuav suav nrog lwm hom lus yog tias muaj. PDF sau thiab luam cov ntawv tuaj yeem ua tiav hauv online thiab luam tawm rau cov ntawv tawv tawv kom kos npe thiab xa hauv lossis xa tuaj rau tus neeg ua haujlwm tsim nyog rau kev ua haujlwm.
Cov Ntawv MC (100):
- MC 171 (05/07) – Medi-Cal Long-Term Care Facility Admission and Discharge Notification
- 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)
- Lwm yam: Mev
- 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 (10/23) – 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) – Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI)Income Eligibility Work Sheet, Couple or Applicant with an Ineligible Spouse, With or Without Child(ren)
- 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 (06/12) – Aged and Disabled Federal Poverty Level Program Financial Eligibility Form
- MC 176 D (05/07) – Medi-Cal Special Treatment Programs
- MC 176 EP (05/07) – Exempt Payment Form
- 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: Spanish
- MC 176 P-A QMB/SLMB/QI (09/08) – Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI)Property Work Sheet, Adult
- MC 176 PA-A (05/07) – Medi-Cal Property Assessment Application
- Alt: Mev (01/09)
- 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 (05/07) – 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) – Vehicle Determination Worksheet for 1931 Group
- MC 176 QMB-3 (05/07) – Qualified Medicare Beneficiary (QMB) Referral
- 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) – Medi-Cal Status Report
- MC 176 TMC (05/07) – Transitional Medi-Cal (TMC) Quarterly Status Report
- Alt: Lus Mev (10/08)
- MC 176 W (05/08) – Allocation/Special Deduction Worksheet MC 176 W.1 (01/24) – Stepparent Computation MC 179 (11/07) – Disability Determination Service Division
- Alt: Spanish (01/08)
- MC 194 (07/12) – Social Security Administration Referral Notice