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加州醫療補助健康保健計劃 資格部門表格按表格編號的字母順序在下面列出，並且可能包括替代語言（如果有）。PDF 填寫和列印表格可以在線填寫，並打印成紙本，以簽名並郵寄或親自提交給合資格工作人員進行處理。​​ 

MC (100) 表格：​​ 

• MC 171 (05/07) – Medi-Cal Long-Term Care Facility Admission and Discharge Notification​​ 
• MC 174 (05/07) - Medi-Cal 給提供者的通知澄清責任 (Eng/Sp)​​  
  •     西班牙語​​ 
• 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)​​  
  •     替代:​​  西班牙語​​ 
• 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:西班牙文 (01/09)
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• 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) - 無資格享受療養院等級護理期間工作表​​  
• 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​​ 
  •     Alt： 阿拉伯語 、 亞美尼亞語 、 中文 、 波斯 語 、 苗語 、 柬埔寨語 、 韓語 、 俄語、 西班牙語 、 他 加祿語 、 越南語​​ 
• MC 176 TMC (05/07) – Transitional Medi-Cal (TMC) Quarterly Status Report​​ 
  •     替代:​​  西班牙文 (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​​ 
  •     其他:西班牙語 (01/08)​​ 
• MC 194 (07/12) – Social Security Administration Referral Notice​​