Form Mc 360 PDF Details

In navigating the complexity of healthcare services, individuals often face administrative challenges that could directly impact their access to necessary care. Among these, the process of transferring Medi-Cal benefits across county lines in California exemplifies a situation where clear communication and precise documentation are critical. The MC 360 form, issued by the State of California Health and Human Services Agency and the Department of Health Care Services, serves as a pivotal document in facilitating this process. It is designed to notify the appropriate parties of a Medi-Cal intercounty transfer. For a successful transition, the form requires comprehensive details including both the receiving and sending counties' information, case and beneficiary information, as well as specifics about the Medi-Cal Family Budget Unit, among other vital data. In essence, the MC 360 form acts as a thorough record that ensures the beneficiary's critical healthcare benefits continue without interruption, underscored by instructions that mandate the completion of every space to avoid any potential gaps in service. Additionally, it encompasses the integration of several other documents, such as Statements of Facts, income verifications, and previous Notices of Action, thereby streamlining the beneficiary's transition into a new county's healthcare system.

QuestionAnswer
Form NameForm Mc 360
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesinter county transfer form, INTERCOUNTY, intercounty transfer form, inter county transfer medi cal form

Form Preview Example

State of California—Health and Human Services Agency

Department of Health Care Services

NOTIFICATION OF MEDI­CAL INTERCOUNTY TRANSFER

Instructions: Complete each space or box. If information does not pertain to this case, indicate with N/A.

Receiving county name and address

Sending county name and address

 

 

Case Name/Beneficiary Information

Case name

 

 

Phone number

Alternate phone number

 

 

 

(

)

(

)

Address (number, street)

City

 

ZIP code

 

 

 

 

 

Authorized representative (AR)

AR name

AR phone number

Beneficiary’s primary language

Yes

No

 

(

)

 

 

 

 

 

 

 

 

 

Receiving county follow­up on changes related to intercounty transfer

Medi­Cal Family Budget Unit (If person is excluded, please indicate.)

Name

Aid Code

Income/How Often Received

Share­of­Cost (SOC)

 

 

Other Case Information

CE for: _________________________________________

CEC for: ________________________________________

CEC period: _____________________________________

TMC period: _____________________________________

Annual redetermination due date: ___________________

LTC period of ineligibility: __________________________

Court case: _____________________________________

Other: _________________________________________

Documents in Transfer Packet

 

Statement of Facts and applicable supplements/MC 210 RV

Pregnancy verification for: _________________________

 

Social security card(s)

 

 

Primary wage earner: _____________________________

 

Identifications

 

 

MC 13s and Proof of Alien Status for: ________________

 

 

 

 

 

 

Case narrative

 

 

_______________________________________________

 

 

 

 

 

 

Budget work sheets for MFBU/MBU

 

Property verifications or MC 176 P

 

 

Family Support Information (CW 2.1s)

 

Computer generated case documents

 

Authorized Representative Form/Letter

 

Last NOAs for share­of­cost

 

 

 

 

 

SP­DDSD Decision/Incapacity Verification for: _________

 

Income verifications

 

 

 

 

 

_______________________________________________

 

Other Health Coverage Information (DHCS 6155)

 

Other(s) (list): ___________________________________

 

 

 

 

 

 

 

 

 

Sending County Worker Information

 

 

 

Worker name

 

 

Worker number

Date ICT packet sent

 

 

 

 

 

Phone number

Fax number

 

E­mail address

 

(

)

(

)

 

 

 

 

 

 

 

 

MC 360 (06/07)

How to Edit Form Mc 360 Online for Free

Using the online PDF editor by FormsPal, you're able to complete or edit inter county transfer medi cal here and now. The tool is continually upgraded by us, receiving cool functions and turning out to be greater. For anyone who is seeking to get going, here's what it will require:

Step 1: First of all, access the tool by clicking the "Get Form Button" above on this webpage.

Step 2: Once you launch the tool, you'll see the form all set to be completed. Other than filling in different blank fields, you can also do some other things with the file, specifically putting on your own words, editing the original text, inserting illustrations or photos, placing your signature to the form, and more.

To be able to complete this form, be sure you type in the right information in each and every blank field:

1. Start completing your inter county transfer medi cal with a group of necessary blanks. Collect all of the important information and be sure there is nothing overlooked!

The right way to fill out NOAs portion 1

2. When this selection of blank fields is completed, proceed to enter the suitable details in these: Name, Aid Code, IncomeHow Often Received, ShareofCost SOC, Other Case Information, CE for CEC for CEC period TMC, Annual redetermination due date, Documents in Transfer Packet, Statement of Facts and applicable, Social security cards, Identifications, Case narrative, Budget work sheets for MFBUMBU, Computer generated case documents, and Last NOAs for shareofcost.

NOAs writing process explained (part 2)

3. Completing Other Health Coverage Information, Sending County Worker Information, Pregnancy verification for, Worker number, Date ICT packet sent, Phone number, Fax number, and Email address is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

NOAs writing process explained (part 3)

In terms of Sending County Worker Information and Pregnancy verification for, ensure that you double-check them in this section. Those two are the most significant ones in the form.

Step 3: After you have glanced through the details you given, click "Done" to conclude your FormsPal process. Right after creating a7-day free trial account here, you'll be able to download inter county transfer medi cal or send it through email without delay. The PDF form will also be accessible via your personal account with all of your adjustments. We do not share or sell any details that you type in while working with documents at our website.