Medi-Cal 资格部门 MC 100 表格
Medi-Cal Eligibility Division (MCED) forms are listed alphabetically below by form number and may include alternate languages if available. PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing.
MC 100 表格：
- MC 171 (05/07) – Medi-Cal Long-Term Care Facility Admission and Discharge Notification
- MC 174 (05/07) – Medi-Cal Notice to Providers Clarification of Liability (Eng/Sp)
- 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)
- 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
- 替代：西班牙语 (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) – Period of Ineligibility for Nursing Facility Level-of-Care Work Sheet
- MC 176 PV (05/07) – 1931 年组车辆鉴定工作表
- 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
- 替代：西班牙语 (10/08)
- MC 176 W (05/08) – 分配/特殊扣除工作表
- MC 176 W.1 (01/24) – Stepparent Computation
- MC 179 (11/07) – Disability Determination Service Division
- 替代：西班牙语 (01/08)
- MC 194 (07/12) – Social Security Administration Referral Notice
- MC 195 (07/17) – 县级转递文件，用于接收 SSI 的 MCIEP 申请人。
- MC 196 (03/20) – Transmittal Form for Notifying DHCS of MCIEP Changes in Status for County Medical Probation or Compassionate Release Inmates