메디칼 자격 부서 MC 300 양식
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Medi-Cal 자격 부서 양식은 아래에 양식 번호별로 알파벳순으로 나열되어 있으며, 가능한 경우 대체 언어가 포함될 수 있습니다. PDF 작성 및 인쇄 양식은 온라인으로 작성하고 하드카피로 인쇄하여 서명한 후 우편으로 보내거나 자격 요건을 갖춘 근로자에게 직접 제출하여 처리할 수 있습니다.
업데이트!
임산부를 위한 모든 추정 자격 양식은 이제 제공자 웹사이트에서 다음 양식에 대해 사용할 수 있습니다:
MC 311
MC 300 양식:
- MC 306 (11/15) – Appointment of Representative
- Alt: 스페인어 (01/08)
- MC 322 (05/07) – Real and Personal Property – Supplement to Medi-Cal Mail-in Application
- MC 326 A (05/07) – Supplemental Security Income (SSI) Methodology Adult Income Eligibility Worksheet MC 326 C (05/07) – Supplemental Security Income (SSI) Methodology Income Worksheet – Eligible Child with Ineligible Parent or Parent(s) MC 327 A (05/07) – Supplemental Security Income (SSI) Program Property Worksheet Adult MC 327 C (05/07) – Supplemental Security Income (SSI) Program Property Worksheet Child
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MC 330 (10/24) – Newborn Referral (Not an Application for Medi-Cal (fillable)
- MC 337 (05/07) – 100 Hours or More Unemployed Parent Determination Work Sheet
- MC 338 (05/07) – 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program – Adults
- Alt: Instructions MC 338 A (05/07) – SSI/SSP Income Test Work sheet For The 250 Percent Working Disabled Program – Adults MC 338 B (05/07) – 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program-Child Applying with or without Ineligible Parent(s) MC 338 C (05/07) – SSI/SSP Property Test Worksheet For The 250 Percent Working Disabled Program – Adults and Child Applicants
- MC 338 J (05/07) – Premium Differential Work Sheet in the 250 Percent Working Disabled Program MC 350 (05/07) – Medi-Cal Notice of Action – Approval For The Medically Needy or Medically Indigent Program Benefits MC 354 (05/07) – Medi-Cal Contact Update
- Alt: 스페인어
- Alt: Instructions MC 338 A (05/07) – SSI/SSP Income Test Work sheet For The 250 Percent Working Disabled Program – Adults MC 338 B (05/07) – 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program-Child Applying with or without Ineligible Parent(s) MC 338 C (05/07) – SSI/SSP Property Test Worksheet For The 250 Percent Working Disabled Program – Adults and Child Applicants
- MC 355 (07/18) – Medi-Cal Request for Information
- MC 356 (05/07) – “Safe Arms for Newborns” Medical Questionnaire
- Alt: Spanish MC 360 (06/07) – Notification of Medi-Cal Intercounty Transfer MC 360 R (05/07) – Medi-Cal Intercounty Transfer Packet Receipt MC 363 (05/07) – Medi-Cal to Healthy Families Transmittal MC 363 S (05/07) – County Summary Transmittal MC 364 (05/07) – California Department of Aging (CDA) Waiver Referral MC 368 (06/07) (Chi) – Notice of Supplemental Form for Express Enrollment Applicants (Chinese)
- MC 368 (06/07) (Hmo) – Notice of Supplemental Form for Express Enrollment Applicants (Hmong)
- MC 368 (06/07) (Rus) – Notice of Supplemental Form for Express Enrollment Applicants (Russian)
- MC 368 A (11/10) – Important Information for Medi-Cal Applicants
- Alt: Spanish MC 368 M (06/07) – Express Enrollment Supplemental Form for Medi-Cal, Healthy Families, and Healthy Kids
- Alt: Spanish MC 370 (06/13) – Healthy Families/Medi-Cal Joint Application Order Form MC 371 (07/09) – Additional Family Members Requesting Medi-Cal
- Alt: 아랍어, 아르메니아어, 중국어, 페르시아어, 몽족어, 캄보디아어, 한국어, 러시아어, 스페인어, 타갈로그어, 베트남어, 베트남어
- MC 372 (12/21) – Breast and Cervical Cancer Treatment Program (BCCTP)
- MC 373 (12/21) – County Referral to the Breast and Cervical Cancer Treatment Program
- MC 380 (06/18) – Notice of Authorized Representative Appointment
- MC 381 (06/18) – Authorized Representative Cancellation Letter
- MC 382 (06/18) – Appointment of Authorized Representative Form
- MC 383 (06/18) – Authorized Representative Standard Agreement
- Alt: 스페인어