Form Mc 330 – Fill Out and Use This PDF

Form Mc 330 is a printed document issued and approved by the United States Department of Homeland Security. It serves as official proof of an individual's involvement in, or affiliation with, certain activities authorized by this agency. Additionally, it is widely accepted–among government employees and contractors alike–as sufficient evidence that an individual has right to access highly sensitive information and/or be present in certain restricted areas. Across America, completing Form Mc 330 accurately and efficiently is critical for gaining access to numerous entities: from military installations to technology companies who produce state of the art equipment for surveillance purposes. As such, individuals need to pay special attention when completing Maternal Child Health & Registrar Services McKesson Corporation (MC330), ensuring safeguards are properly implemented and adhering to high standards of conduct established by US officials.

Form Mc 330 PDF Details

Form Mc 330 is a document that is used to report or dissolve a limited liability company (LLC). This form must be filed with the Oklahoma Secretary of State. The purpose of this document is to provide information about the company and its members. There are several specific items that must be included on Form Mc 330, so it is important to understand what is required before filing. If you need assistance completing this form, or have any other questions about LLCs, please contact our office for more information. Thank you for your interest in Oklahoma businesses!

Question	Answer
Form Name	Form Mc 330
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	Yuba, SSN, medical newborn referral form, Nevada

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State of California—Health and Human Services Agency

Department of Health CARE Services

NEWBORN REFERRAL

(NOT AN APPLICATION FOR MEDI-CAL)

(PLEASE USE INK AND PRESS FIRMLY.)

The Newborn Referral Form is used to assist a Medi-Cal eligible mom to report the birth of her child(ren) to Medi-Cal. By completing the information on this form, you help the county confirm the eligibility of the newborn. Mail or fax this form to the county. County information is located on the back of this form. Any changes to the household must be reported to the county, so, turn in this information quickly. The mother may also report the birth by phone to her eligibility worker. If you are acting on behalf of the mother and are not a spouse, relative, or guardian, then your signature and identifying information is required in Section C. If entering through Gateway Program enter the BIC number assigned to the infant (optional).

SECTION A The mother’s Medi-Cal card can be used during the birth month and the month following for services and billing for the newborn.

Mother’s name (first, MI, last)		Mother’s date of birth			BIC or Medi-Cal ID number or SSN

Mailing address (number and street) or location					County

City	State	ZIP code			Telephone number
					(	)

SECTION B Reminder: A child born to a mother with restricted benefits is eligible for full-scope benefits.

Newborn name (first, MI, last)		Date of birth (month/day/year)		Gender				Optional—Gateway ID number
					Male	Female

Newborn 2 name (first, MI, last)		Date of birth (month/day/year)		Gender				Optional—Gateway ID number
					Male	Female

Newborn 3 name (first, MI, last)		Date of birth (month/day/year)		Gender				Optional—Gateway ID number
					Male	Female

Where born (hospital name, clinic name, etc.)

Address (number and street, if available)			City				State		ZIP code

Will baby and mother live in the same household?

If no, has the mother given up rights to the newborn child? If yes, date child(ren) given up: ______/______/______

Yes Yes

No No

This form does not start Medi-Cal, CalWORKs, or Food Stamp benefits. If you currently get these benefits, you must contact your eligibility worker to continue getting these benefits.

I hereby authorize release of this information to the County Department of Social Services/county welfare department.

Date of request

Parent/Relative/Guardian (of the infant) signature

⌦

SECTION C (Fill in this section if form was completed by person other than parent, relative, or guardian.)

Completed by (PLEASE PRINT)	Title

Medi-Cal ID number (If Medi-Cal provider/hospital/clinic/group, etc.)	Telephone number
	(	)

I certify to the best of my knowledge that the information above is verified and accurate.

Signature (person other than parent, relative, or guardian)

⌦

Date completed

For provider billing inquiries concerning or how to bill for infants, call the EDS Billing Hotline at 1-800-541-5555.

Distribution:

White—County

Yellow—Hospital/Clinic/Nurse-Midwife/CAA/AR

Pink—Parent/Relative/Guardian

MC 330 (06/07)

Newborn Referral

County Central Location Phone List

	Department Name	County Number	FAX Number	Department Name			County Number	FAX number
1	Alameda Co Social Services Agency	510-259-3882	510 259-3880	30 Orange Co Social Services Agency				714-435-4625

2	Alpine Co Department of Social Services	530-694-2235	530-694-2252	31	Placer Co Health and Human Services		530-889-7617	530-889-6826

3	Amador Co Department of Social Services	209-223-6621	209-223-6208	32 Plumas Co Department of Social Services			530-283-6350	530-283-6368

4	Butte Co Department of Social Services	None	530-879-3468	33	Riverside Co DPSS/APD Section		909-358-3000	909-358-3990

5	Calaveras Co Work & Human Services Agency	209-754-6447	209-754-6543	34	Sacramento Co Dept of Human Asst/Newborn Referral		916-395-4551	916-875-3591

6	Colusa Co Department of Health & Human Services	530-458-0264	530-458-0492	35	San Benito Co Human Services Agency		831-637-5336	831-637-9754

7	Contra Costa Co Employment & Human Services	None	925-313-1758	36	San Bernardino Co DPSS		909-388-0280	909-383-9714

8	Del Norte Co Dept of Health and Social Services	707-464-3191	707-465-1783	37	San Diego Co DHHS /DSS		858-262-9881	858-514-6760

9	El Dorado Co Department of Social Services	530-642-7159	530-626-9060	38 San Francisco Co Department of Human ServiceS			415-558-1994	415-558-1841

10	Fresno Co Human Services System	None	559-253-9250	39	San Joaquin Co Human Services Agency		209-468-1487	209-468-1985

11	Glenn Co Human Resources Agency	None	530-934-6521	40	San Luis Obispo Co Dept of Social Services		805-781-1600	805-781-1846

12	Humboldt Co Department of Social Services	707-441-2047	707-441-5600	41	San Mateo Co Human Services Agency		650-802-7570	650-595-7576

13	Imperial Co Department of Social Services	760-337-6800	760-370-0492	42	Santa Barbara Co Department of Social Services		805-681-4528	805-737-7098

14	Inyo Co Department of Social Services	760-872-1394	760-872-4950	43	Santa Clara Co Social Services Agency	1-800-753-0024		408-792-1890

15	Kern Co Department of Human Services	661-631-6046	661-631-6631	44	Santa Cruz Co Human Resources Agency		831-454-4316	831-763-8530

16	Kings Co Human Services Agency ext 2270	209-583-3241	559-584-2749	45	Shasta Co Department of Social Services		530-225-5750	530-225-5087

17	Lake Co Department of Social Services	707-995-4201	707-995-4204	46	Sierra Co Social Services		530-993-6720	530-993-6741

18	Lassen Co WORKS	530-251-8346	530-251-8370	47	Siskiyou Co Human Services		530-841-2752	530-841-2790

19	Los Angeles Co M/C Mail-In Application DISTRICT	213-763-7637	213-763-8666	48 Solano Co Health & Social Services			707-553-5311	707-421-7237

20	Madera Co Department of Social Services	209-675-2403	559-675-7983	49	Sonoma Co Social Services Department		707-527-2715	707-565-5353

21	Marin Co Department of Health and Human Services	415-473-3400	415-473-3556	50	Stanislaus Co Department of Social Services		209-558-4822	209-558-2558

22	Mariposa Co Department of Human Services	209-966-3609	209-966-5943	51	Sutter Co Department of Human Services		530-822-7230	530-822-7212

23	Mendocino Co Department of Social Services	707-463-7760	707-463-5404	52	Tehema Co Department of Social Services		530-528-4081	530-527-5410

24	Merced Co Human Services Agency	209-385-3000	209-725-3583	53	Trinity Co Health and Human Services Dept		530-623-8236	530-623-1250

25	Modoc Co Department of Social Services	530-233-6501	530-233-6504	54	Tulare Co Department of Public Social Services		559-685-4825	559-685-2529

26	Mono Co Department of Social Services	760-932-7291	760-924-5431	55	Tuolumne Co Department of Social Services		209-533-5711	209-533-5714

27	Monterey Co Department of Social Services	805-755-4662	831-755-8408	56	Ventura Co Public Social Services Agency		805-652-7618	805-652-7845

28	Napa Co Health and Human Services	707-253-4697	707-253-4693	57	Yolo Co Department of Employment & Social Services		530-661-2750	530-661-2658

29	Nevada Co Adult and Family Services	530-265-7101	530-265-7062	58	Yuba Co Department of Social Services		530-749-6311	530-749-6281

MC 330 (06/07)

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With regards to the fields of this precise form, here's what you should know:

1. Begin filling out your Los with a selection of necessary blanks. Collect all the required information and make certain there's nothing missed!

2. The next stage is usually to submit all of the following blanks: Will baby and mother live in the, If no has the mother given up, If yes date children given up, Yes, Yes, This form does not start MediCal, I hereby authorize release of this, ParentRelativeGuardian of the, SECTION C Fill in this section if, Completed by PLEASE PRINT, Title, MediCal ID number If MediCal, Telephone number, I certify to the best of my, and Signature person other than parent.

As to SECTION C Fill in this section if and Signature person other than parent, make sure that you don't make any mistakes here. The two of these are considered the key ones in this form.

3. Completing Distribution, WhiteCounty, and PinkParentRelativeGuardian is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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Form Mc 330 – Fill Out and Use This PDF

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