Form Mc 311 PDF Details

Form Mc 311 is a form used by the United States Citizenship and Immigration Services (USCIS) to notify an individual of their rights and responsibilities as a conditional resident. This form is also used to request evidence that the individual has satisfied the requirements for permanent residence. Conditional residents must file Form I-751 within 90 days of their second anniversary in order to remove the conditions on their residency. Failure to do so may result in removal from the United States. Receiving this form is therefore very important, and individuals should take care to read it carefully and respond accordingly.

QuestionAnswer
Form NameForm Mc 311
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namescalifornia, 2005, seq, CPSP

Form Preview Example

`State of California—Health and Human Services Agency

Department of Health Care Services

QUALIFIED PROVIDER APPLICATION FOR PRESUMPTIVE ELIGIBILITY PARTICIPATION

Presumptive Eligibility Support Unit MS 4607

P.O. Box 997417 Sacramento, CA 95899-7417 1-800-824-0088

1-800-409-1498 (FAX)

This is an application to become a Qualified Provider for the Presumptive Eligibility (PE) for Pregnant Women Program for the purposes of offering Presumptive Eligibility (temporary Medi- Cal) to your pregnant patients. You must provide prenatal services to qualify for Presumptive Eligibility participation. Please complete, sign, and return this application to the PE for Pregnant Women Support Unit.

If you have questions about this application or the PE for Pregnant Women program, contact the PE Support Unit at 1-800-824-0088. For general information about PE for Pregnant Women, visit the web site at www.medi-cal.ca.gov.

FOR OFFICIAL USE ONLY

Date Received: _________________________

PE Number: ___________________________

Authorization Code: _____________________

PART I

Check only one:

PRIMARY CARE CLINIC THAT IS NOT YET A MEDI-CAL PROVIDER: AB 2307 (Chapter 1, Statutes of 2004 [effective July 1, 2005]) allows Primary Care Clinics to apply for Presumptive Eligibility participation while waiting to be determined as a Medi-Cal provider. No provider number is needed at the time of this application, or

MEDI-CAL PROVIDER: When applying, you must include your provider number here:

NOTE: This number must match the site applying for PE participation. The provider at this site must be a provider in good standing. If you do not have a provider number, contact the Department of Health Care Services Provider Enrollment Division at (916) 323-1945.

PART II

1. Name of provider

Other name (if any used for provider services)

2. County

Telephone number

()

FAX number

()

3. Service address (no P.O. Box) for Site

City

ZIP Code

4. Contact person

Telephone number

()

FAX number

()

5.Please estimate the number of pregnant patients your practice sees each month that are not covered by health insurance or Medi-Cal at the time of their initial pregnancy visit.

Of this number, how many do you expect will need Spanish language forms?

PART III

1.Do you participate in the Comprehensive Perinatal Services Program (CPSP)?

NOTE: If you are not currently a CPSP provider, you may get information on how to enroll by contacting the Department of Health Care Services, Maternal and Child Health Branch at (916) 650-0401.

2.Do you participate in the Family PACT (Planning, Access, Care, and Treatment) Program?

NOTE: If you are not currently a Family PACT provider, you may get information on how to enroll by contacting the Department of Health Care Services at (800) 541-5555.

Yes

Yes

No

No

PART IV

CERTIFICATION

I hereby certify that all the above information is true and accurate to the best of my knowledge.

Signature

Title of Authorized Agent

Date

All information submitted with this application will be part of a file that is open for public inspection pursuant to the California Public Records Act, Government Code, Section 6250, et seq.

If you have questions about becoming a qualified provider for the PE for Pregnant Women program, please contact PE Support at 1-800-824-0088.

MC 311 (10/07)

Page 1 of 2

PRESUMPTIVE ELIGIBILITY

QUALIFIED PROVIDER RESPONSIBILITIES AND AGREEMENT

I understand that my responsibilities as a Qualified Provider include:

Offering PE for Pregnant Women to my pregnant patients without health coverage or Medi-Cal;

Screening interested patients for income eligibility via the prescribed forms and guidelines;

Issuing eligible applicants a Proof of Eligibility card, two copies of the one-page Medi-Cal application form, and issuing replacement cards to recipients upon request;

Renewing the Proof of Eligibility card when the woman presents a copy of her timely application for Medi-Cal or Cash Aid.

Informing the pregnant patient at the time of the PE determination that she must apply for Medi-Cal (or Cash Aid) within a specified period of time in order for her PE coverage to continue. Assisting the pregnant patient in completing her one-page Medi-Cal application if needed;

Providing a written statement to the applicant if she is ineligible for PE for Pregnant Women benefits, and informing her that she may still file for Medi-Cal (or Cash Aid) at the county Health and Human Services office;

Notifying the Department of Health Care Services within five working days with the required information on those patients eligible for Presumptive Eligibility and those not eligible due to a negative pregnancy test;

Maintaining organized records of PE for Pregnant Women program applications for three years from the last date of billing, making these records available to the Department of Health Care Services upon request, and permitting periodic Department review of the records with adequate notice from the Department;

Attending training and keeping current with changes affecting PE for Pregnant Women through provider bulletins, notices, and/or further training.

I, (print name) _______________________________, agree to cooperate with the Department of Health Care

Services in complying with the above Qualified Provider responsibilities. I am aware that if I do not comply with these responsibilities and the PE for Pregnant Women guidelines as outlined in the Medi-Cal Provider Manual, I may lose my status as a Qualified Provider. I agree to notify the Department of Health Care Services in writing of any changes in my application information at least 10 days prior to the effective date of the change.

___________________________________________________________

_____________________________________

_______________________

Signature

Title of Authorized Agent

Date

MC 311 (10/07)

Page 2 of 2

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2004 writing process outlined (portion 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Contact person, Telephone number, FAX number, Please estimate the number of, by health insurance or MediCal at, Of this number how many do you, PART III, Do you participate in the, Yes, NOTE If you are not currently a, the Department of Health Care, Do you participate in the Family, Yes, NOTE If you are not currently a, and contacting the Department of with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

2004 conclusion process explained (stage 2)

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Signature, Title of Authorized Agent, and Page of inside 2004

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