Forms: MC 100​​ 

• MC 171 (05/07) - Medi-Cal Lub Chaw Saib Xyuas Lub Sijhawm Ntev Nkag Nkag thiab Tshaj Tawm​​ 
• MC 174 (05/07) - Medi-Cal Daim Ntawv Ceeb Toom rau Cov Muab Kev Qhia Kom Paub Txog Lub Luag Haujlwm (Eng/Sp)
  Alt: Spanish​​ 
• MC 175 I (05/07) - Sneede v. Kizer Cov Lus Nug Txog Cov Nyiaj Tau Los​​ 
• 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) - Ntu 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Kev Txiav Txim - Tus neeg thov​​ 
• MC 175-3I.2R (05/07) - Tshooj 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Kev Txiav Txim - Tus neeg txais​​ 
• 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 (05/07) - Sneede v. Kizer Mini Budget Units Thiab:​​ 
• MC 175-5 (05/07) - Tsoom Fwv Teb Chaws Qib Kev Txom Nyem (FPL) Cov Kev Pabcuam rau Cov Poj Niam Cev Xeeb Tub thiab Me Nyuam (Cov Nyiaj Tau Los Tsis Txaus Siab, 200 Feem pua); Cov me nyuam hnub nyoog 1 txog 5 xyoos (133 feem pua); thiab cov menyuam hnub nyoog 6 txog 18 xyoo (100 feem pua) (Rau Lub Nroog Tsuas Siv)​​ 
• MC 175-6 (05/07) - Sneede v. Kizer Allocation los ntawm SSI lossis IHSS Tus Neeg​​ 
• MC 175-7 (05/07) - Sneede v. Kizer Allocation Work Sheet Board and Care Person to txij nkawm thiab/los yog menyuam yaus hauv tsev los yog LTC Tus Neeg (AFDC/MN/MI) Tsis muaj zej zog tus txij nkawm rau menyuam yaus hauv tsev​​ 
• MC 176-1 QMB/SLMB/QI (05/07) - Tsim nyog Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Daim Ntawv Thov Kev Tsim Nyog Rau Txhua Tus Neeg Thov Kev Pab: Tus Kheej (cov) Cov Neeg Tau Txais Kev Pab (cov) Cov Neeg Tau Txais Nyiaj Tsawg (SLMB)​​ 
• MC 176-2A QMB/SLMB/QI (09/08) - Tsim nyog Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Cov Nyiaj Tau Los Ntawm Kev Tsim Nyog Ua Haujlwm, Cov khub niam txiv lossis tus neeg thov kev pabcuam uas tsis muaj cai Tus txij nkawm, nrog lossis tsis muaj menyuam​​ 
• MC 176-2B QMB/SLMB/QI (05/07) - Tsim nyog Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Cov Nyiaj Tau Los Tsim Nyog Ua Haujlwm, Tus Me Nyuam Ua Ntawv Thov nrog lossis tsis muaj Niam Txiv Tsis Tsim Nyog ( s)​​ 
• MC 176 AD (10/20) - Cov Neeg Laus thiab Cov Neeg Tsis Muaj Peev Xwm Federal Poverty Level Program Kev Tsim Nyog Nyiaj Txiag​​ 
• MC 176 D (05/07) - Medi-Cal Kev Kho Mob Tshwj Xeeb​​ 
• MC 176 EP (05/07) - Exempt Payment Form​​ 
• MC 176 M (05/07) - Qhia tawm ntawm Kev Txiav Txim Nqi - MFBUs Uas Tsis Muaj LTC Cov Neeg​​ 
• MC 176 MA Applicant-Recipient (05/07) - Seem 1931 Daim Ntawv Thov Kev Pabcuam/Tus Neeg Txais Nyiaj: Rau Kev Txiav Txim Cov Nyiaj Tau Los Tsis Tau Txais thiab Tshooj 1931 Cov Nyiaj Tau Los Tsim Nyog rau Cov Neeg Thov; Thiab rau cov neeg tau txais kev pab nyob rau hauv Alternative B​​ 
• MC 176 MA Recipient (05/07) - Tshooj 1931 Daim Ntawv Nyiaj Tau Txais: Rau Kev Txiav Txim Cov Nyiaj Tau Los Tsis Tau Txais thiab Tshooj 1931 Cov Nyiaj Tau Los Tsim Nyog Rau Cov Neeg Tau Txais Raws Li Lwm Txoj Cai A​​ 
• MC 176 M-LTC (11/07) - Qhia tawm ntawm Kev Txiav Txim Nqi - MFBUs nrog LTC Cov Neeg Muaj - LTC​​ 
• MC 176 P (05/07) - Property Reserve Worksheet​​ 
• MC 176 PA-1/PA-2 (05/07) - Property Worksheet/Sessment for Institutionalized Spouses (Eng/Sp)
  Alt: Spanish​​ 
• MC 176 PA QMB/SLMB/QI (09/08) - Tsim nyog Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Property Work Sheet, Adult​​ 
• MC 176 PA-A (05/07) - Medi-Cal Daim Ntawv Thov Kev Soj Ntsuam Cov Khoom
  Alt: Spanish (01/09)​​ 
• MC 176 PC QMB/SLMB/QI (05/07) - Tsim nyog Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Daim Ntawv Ua Haujlwm, Tus Me Nyuam​​ 
• MC 176 PI (07/22) - Lub Sijhawm Tsis Tsim Nyog rau Cov Chaw Saib Xyuas Neeg Mob Qib-ntawm-Care Daim Ntawv Ua Haujlwm​​ 
• MC 176 PV (05/07) - Daim Ntawv Qhia Txog Kev Txiav Txim Tsheb rau 1931 Pawg​​ 
• MC 176 QMB-3 (05/07) - Tsim nyog Medicare Beneficiary (QMB) xa mus​​ 
• MC 176 QDWI (05/07) - Tsim Nyog Muaj Peev Xwm Ua Haujlwm Ib Tus Neeg Tsis Taus (QDWI) Cov Nyiaj Tau Los Tsim Nyog Ua Haujlwm-Cov Lus Qhia​​ 
• MC 176 QDWI-2 (05/07) - Tsim Nyog Muaj Peev Xwm Ua Haujlwm Ib Tus Neeg Ua Haujlwm (QDWI) Cov Ntawv Ua Haujlwm​​ 
• MC 176 S (03/09) - Medi-Cal Status Report (English)
  Alt: Arabic, Armenian, Suav, Farsi, Hmong, Cambodian, Korean, Russian , Spanish, Tagalog, Vietnamese​​ 
• MC 176 TMC (05/07) - Transitional Medi-Cal (TMC) Quarterly Status Report
  Alt: Spanish (10/08)​​ 
• MC 176 W (05/08) - Daim Ntawv Qhia Txog Kev Txiav Txim Tshwj Xeeb​​ 
• MC 176 W.1 (05/07) - Stepparent Computation​​ 
• MC 179 (11/07) - Disability Determination Service Division
  Alt: Spanish (01/08)​​ 
• MC 194 (07/12) - Daim Ntawv Ceeb Toom Txog Kev Ruaj Ntseg Hauv Zej Zog​​ 
• MC 195 (07/17) - Lub Nroog Transmittal rau MCIEP Cov neeg thov tau txais SSI​​ 
• MC 196 (03/20) - Daim Ntawv Tshaj Tawm Txog Kev Ceeb Toom DHCS ntawm MCIEP Cov Kev Hloov Pauv hauv Cov Txheej Txheem rau County Medical Probation lossis Compassionate Release Inmates​​ 

Rov qab mus rau Forms Index​​