Medi-Cal Eligibility Division MC 200フォーム
Medi-Cal Eligibility Division(MCED)フォームは、フォーム番号ごとにアルファベット順にリストされており、利用可能な場合は別の言語が含まれている場合があります。PDFの記入および印刷フォームは、オンラインで記入し、ハードコピーに印刷して署名し、郵送するか、処理のために適格労働者に直接提出することができます。
更新！
妊娠中の女性のためのすべての推定適格性フォームは、次のフォームについて、プロバイダーのWebサイトで利用できるようになります。
MC 263-SR、MC 264、MC 265、MC 266、MC 267、MC 283、MC 285、MC 286
MC 200フォーム:
- MC 209 (05/12) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
- MC 210 A (09/07) – Supplement to Statement of Facts for Retroactive Coverage/Restoration
- Alt: スペイン語
- MC 210 B (05/07) – Supplement to Statement of Facts (PICKLE Eligibility/Determination)
- Alt: スペイン語
- MC 210 PA (05/07) – Property Assessment Statement of Facts
- Alt: スペイン語
- 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)
- Alt: スペイン語
- 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
- Alt: スペイン語
- MC 212 (05/07) – Medi-Cal Residency Declaration (Eng/Sp)
- MC 214 (05/07) – Important Information About Residency
- Alt: スペイン語
- 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
- Alt: スペイン語
- MC 220 14pt (04/08) – Authorization for Release of Information (Large Print)
- Alt: スペイン語
- 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
- Alt: スペイン語
- MC 262 (06/07) – Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
- Alt: スペイン語
- MC 272 (05/07) – SGA Work Sheet
- MC 273 (05/07) – Work Activity Report
- Alt: スペイン語
- MC 274 TB (05/07) – Medi-Cal Tuberculosis Program Application
- Alt: スペイン語
- 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