Form Soc 310 PDF Details

In the State of California, navigating the pathway to securing In-Home Supportive Services (IHSS) necessitates a thorough understanding of various forms and procedures, among which the SOC 310 form plays a crucial role. This form acts as a comprehensive statement of facts, crafted to assess the eligibility of applicants under the Welfare and Institutions Code Section 12300. By meticulously gathering information ranging from personal details, residency, financial resources, to household composition and medical insurance, the SOC 310 form enables the California Department of Social Services to make informed decisions regarding an applicant's need for in-home care. This form not only delves into the applicant's living arrangement and assets but also scrutinizes income sources, employment status, and property ownership. Furthermore, it addresses specific queries related to disabilities, thereby ensuring that those with special needs are considered carefully. The meticulousness of the form underscores the state's commitment to providing tailored supportive services, ensuring that assistance is rendered to those genuinely in need. To navigate this process successfully, an accurate and complete provision of requested information is imperative, as is an understanding of the responsibilities and potential repercussions, including the recovery of Medi-Cal benefits under specified conditions. Thus, the SOC 310 form stands as a foundational step in the journey toward acquiring essential in-home supportive care for eligible California residents, highlighting the nuanced interplay between personal circumstances and state-provided health services.

QuestionAnswer
Form NameForm Soc 310
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesBIRTHDATE, SHAREOFCOST, CHAMPUS, california department of social services forms

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STATE OF CALIFORNIA – HEALTH AND HUMAN SERVICES AGENCY

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES

STATEMENT OF FACTS FOR IN-HOME SUPPORTIVE SERVICES

NOTE: Your eligibility for In-Home Supportive Services (IHSS), under Welfare and Institutions Code Section 12300, will be determined by the information you provide on this form.

1.APPLICANT INFORMATION

NAME (FIRST, MIDDLE, LAST)

 

 

 

 

 

 

 

 

 

 

BIRTHDATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOME ADDRESS

 

 

 

 

 

 

 

CITY

 

 

 

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (IF DIFFERENT)

 

 

 

 

 

HOME PHONE

 

 

MESSAGE PHONE

 

 

 

 

 

 

 

 

 

(

)

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLACE OF BIRTH

 

 

SOCIAL SECURITY NUMBER

MEDI-CAL CARD NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ARE YOU:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ AGE 65 OR OVER?

 

■ DISABLED?

 

 

 

■ BLIND?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MARITAL STATUS:

■ MARRIED

 

■ SEPARATED

■ WIDOWED

 

 

■ DIVORCED

■ SINGLE

 

 

 

(Date /

/ )

 

(Date / / )

 

(Date /

/ )

 

 

(Date / / )

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COMPLETE THE FOLLOWING:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF SPOUSE OR PARENT(S) (IF YOU ARE UNDER 18 YEARS OF AGE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IS SPOUSE/PARENT(S):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ AGE 65 OR OVER?

■ DISABLED?

 

 

 

■ BLIND?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE/PARENT(S) SOC. SEC. NO.

SPOUSE/PARENT(S) ADDRESS (IF DIFFERENT THAN APPLICANT'S)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

DO YOU RESIDE IN CALIFORNIA WITH THE

 

 

 

 

 

 

■ YES

■ NO

 

INTENTION TO CONTINUE RESIDING HERE?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

ARE YOU A CITIZEN OF THE UNITED STATES?

 

 

 

■ YES

■ NO

 

(IF “YES”, GO TO “ITEM 4”)

 

 

 

 

 

 

 

 

 

(A.) IF YOU ARE NOT A UNITED STATES CITIZEN, ARE YOU

 

 

 

 

 

 

 

 

 

 

LAWFULLY ADMITTED TO PERMANENT RESIDENCE OR

 

 

 

■ YES

■ NO

 

LEGALLY PERMITTED TO REMAIN IN THE U S.?

 

 

 

(B.) WHAT IS YOUR ALIEN REGISTRATION NUMBER? (C.) WHAT IS NAME OF SPONSOR?

(D.) WHAT IS SPONSOR’S ADDRESS?

4.WHAT IS YOUR LIVING ARRANGEMENT?

MY HOME IS A: ■ HOUSE ■ APARTMENT

■

 

ROOM &

TRAILER/

 

■ OTHER

ROOM ■ BOARD

■ MOTOR HOME

IN WHICH I:

OWN/

 

 

LIVE

RECEIVE

 

 

 

■ AM BUYING

■ RENT

 

■ COST FREE

■ BOARD AND CARE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LANDLORD’S NAME

 

 

 

 

AMOUNT OF RENT, BOARD AND/OR MORTGAGE PAID

 

 

 

 

 

$______________/MONTH

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

CITY

 

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. ARE THERE OTHERS LIVING IN THE HOUSEHOLD?

 

 

 

■ YES

■ NO

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME

 

 

 

 

RELATIONSHIP

 

 

AGE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR COUNTY USE ONLY

SOC 310 (1/03)

Page 1 of 4 pages

6.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) OWN REAL PROPERTY OTHER THAN YOUR HOME?

■ YES

■ NO

FOR COUNTY USE ONLY

(If “YES”, GIVE THE INFORMATION BELOW:

OR ON PAGE 4 PARAGRAPH 21.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

CITY

 

 

 

 

COUNTY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

 

 

 

 

 

ZIP CODE

 

PARCEL NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSESSED VALUE

 

 

 

TOTAL AMOUNT OWED ON MORTGAGE(S)

 

 

MONTHLY PAYMENT

 

 

$

 

 

 

 

 

$

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ANNUAL TAXES

 

ANNUAL INSURANCE

 

 

ANNUAL ASSESSMENTS

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HOW IS PROPERTY UTILIZED?

 

IF USED AS RENTAL, INDICATE

 

 

ARE TAXES INCLUDED IN THE

■ YES

■ NO

 

 

 

 

 

AMOUNT OF RENT.

 

 

MONTHLY PAYMENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER PROPERTY EXPENSES

 

 

 

 

 

 

 

 

IS INSURANCE INCLUDED IN

■ YES

■ NO

 

 

 

 

 

 

 

 

 

 

 

 

THE MONTHLY PAYMENT?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) OWN MOTOR VEHICLES (CARS, TRUCKS,

 

 

 

■ YES

■ NO

 

MOTORCYCLES, BOATS, MOTORHOMES)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAKE AND

 

 

 

ESTIMATED

 

CHECK IF USED FOR

MODIFIED

 

 

MODEL

 

YEAR

 

VALUE

 

WORK

 

MEDICAL

FOR DISABLED

 

 

 

 

 

 

 

 

TRANS.

PERSON?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

WHAT IS THE VALUE OF YOUR LIQUID RESOURCES?

(IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER AGE 18, INCLUDE RESOURCES OF PARENT(S) RESPONSIBLE FOR CHILD, INDICATE IF ANY RESOURCE IS EXCLUSIVELY FOR BURIAL EXPENSES FOR YOU OR YOUR IMMEDIATE FAMILY.)

LIQUID RESOURCES

(✓) IF

 

 

ENTER VALUE UNDER OWNER

(✓) FOR

 

NONE

 

SELF

SPOUSE/PARENTS

JOINTLY

BURIAL

 

 

 

 

 

 

 

 

CASH ON HAND AND/OR

 

 

$

 

$

$

 

MONEY KEPT IN THE HOME

 

 

 

 

 

 

 

 

 

 

 

CHECKING ACCOUNT

 

 

$

 

$

$

 

 

 

 

 

 

 

 

 

SAVINGS ACCOUNT, CREDIT UNION

 

 

$

 

$

$

 

TRUST FUNDS

 

 

 

 

 

 

 

 

 

 

 

CHECKS OR CASH IN SAFETY DEPOSIT

 

 

$

 

$

$

 

BOX

 

 

 

 

 

 

 

 

 

 

 

STOCKS, BONDS, OR MUTUAL FUNDS

 

 

$

 

$

$

 

NOTES, MORTGAGES, DEEDS

 

 

 

 

 

 

 

 

 

 

 

IRA, CERTIFICATES OF DEPOSIT, MONEY

 

 

$

 

$

$

 

MARKET

 

 

 

 

 

 

 

 

 

 

 

OTHER (SPECIFY):

 

 

$

 

$

$

 

 

 

 

 

 

 

 

 

DO YOU, YOUR SPOUSE OR PARENT(S) (IF APPLICANT IS UNDER 18) HAVE ANY PERSONAL GOODS

9.OR HOUSEHOLD EFFECTS WITH A COMBINED EQUITY VALUE OF MORE THAN $2,000?

 

(E. G., HOUSEHOLD FURNISHINGS, CLOTHING, AND JEWELRY.)

(IF ADDITIONAL SPACE IS NEEDED,

■ YES

■ NO

 

SPECIFY IN ITEM 21.)

 

 

 

 

 

 

(IF “YES”, GIVE INFORMATION BELOW:) (EXCLUDE REHABILITATION DEVICES AND EQUIPMENT.)

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION

 

 

 

CURRENT MARKET VALUE

 

AMOUNT OWED

 

 

 

 

 

 

 

 

 

A.

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

B.

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

C.

 

 

$

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY LIFE INSURANCE?

■ YES

■ NO

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF OWNER

NAME OF INSURED

 

NAME AND ADDRESS OF INSURANCE COMPANY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICY NUMBER

TOTAL FACE

VALUE OF POLICY

CASH SURRENDER

VALUE

WHEN WAS THE

POLICY PURCHASED

IF THERE IS A LOAN AGAINST THE POLICY WHAT IS THE AMOUNT

Page 2 of 4 pages

11. DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY BURIAL FUNDS, INSURANCE,

■ YES ■

 

FOR COUNTY USE ONLY

TRUSTS, SPACES OR CONTRACTS? (IF “YES”, GIVE THE INFORMATION BELOW:)

NO

 

 

 

 

 

 

 

OWNER OF

NAME OF

TOTAL PURCHASE

HOW MUCH IS OWED

NAME AND ADDRESS OF

 

 

EACH ITEM

EACH ITEM

VALUE OF EACH ITEM

ON EACH ITEM

COMPANY/SOURCE

 

 

$

$

12.HAVE YOU, YOUR SPOUSE OR PARENT(S) (IF A MINOR IS APPLYING) SOLD, TRANSFERRED

 

OR GIVEN AWAY ANY PROPERTY, INCLUDING MONEY, IN THE LAST 36 MONTHS?

 

 

■ YES

■ NO

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION

DATE OF

 

ESTIMATED

AMOUNT

 

TRANSFER

 

VALUE

 

RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

$

 

 

 

 

 

 

 

 

13.

ARE YOU OR YOUR SPOUSE EMPLOYED OR SELF—EMPLOYED? (IF “YES”, GIVE THE

 

■ YES

■ NO

INFORMATION BELOW:) (IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER I8 INCLUDE

 

 

 

 

EMPLOYMENT OF PARENT(S).)

 

 

 

 

 

 

NAME OF EMPLOYER

ADDRESS OF EMPLOYER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OCCUPATION

GROSS SALARY PER PAY PERIOD

HOW OFTEN PAID?

 

$

IF SELF-EMPLOYED, ATTACH VERIFICATION OF ALL ORDINARY AND NECESSARY BUSINESS EXPENSES, PRINCIPAL

PAYMENTS OR ENCUMBRANCES AND PERSONAL INCOME TAX.

14.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE ANY BUSINESS EQUIPMENT

 

 

INVENTORY, OR MATERIAL?

 

 

 

■ YES

■ NO

 

 

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DESCRIPTION

 

PURPOSE

ESTIMATED

AMOUNT OWED

 

 

 

VALUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

IF YOU ARE BLIND OR DISABLED AND WORKING, DO YOU HAVE ANY WORK—RELATED

 

 

EXPENSES DUE TO BLINDNESS OR DISABILITY?

 

■ YES

■ NO

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

 

 

COST OF TRANSPORTATION TO AND FROM

COST OF ITEMS OR SERVICES TO PREPARE

COST OF ITEMS OR SERVICES

 

 

WORK

 

FOR WORK

NEEDED FOR JOB PERFORMANCE

 

$

 

$

 

$

 

 

16.LIST INCOME RECEIVED EACH MONTH FROM SOURCES OTHER THAN EMPLOYMENT. IF APPLICANT IS A BLIND OR DISABLED CHILD UNDER AGE 18, INCLUDE INCOME OF PARENT(S) RESPONSIBLE FOR CHILD.

 

TYPE OF INCOME

(✓)

ENTER MONTHLY AMOUNT RECEIVED BY:

CLAIM NUMBER

 

 

NONE

SELF

SPOUSE/PARENT(S)

 

 

 

 

 

 

 

 

 

 

 

 

A.

SOCIAL SECURITY

(RETIREMENT, SURVIVOR,

 

$

$

 

 

DISABILITY INSURANCE)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

CASH CONTRIBUTIONS

 

$

$

 

 

 

 

 

 

 

 

 

 

 

STATE DISABILITY/

 

 

$

$

 

 

C.

UNEMPLOYMENT INSURANCE

 

 

 

 

 

 

 

 

 

 

D.

VETERAN’S PENSION/COMPENSATION

 

$

$

 

 

 

 

 

 

 

 

 

 

V.A. AID AND ATTENDANCE

 

$

$

 

 

E.

CARE/ HOUSEBOUND ALLOWANCE

 

 

 

 

 

 

 

 

 

 

F.

GOVERNMENT PENSION

 

$

$

 

 

 

 

 

 

 

 

 

 

PRIVATE AND/OR MILITARY

 

$

$

 

 

G.

RETIREMENT PENSION

 

 

 

 

 

 

 

 

 

 

H.

ALIMONY, CHILD SUPPORT

 

$

$

 

 

 

 

 

 

 

 

 

 

I.

RENTAL INCOME

 

 

$

$

 

 

 

 

 

 

 

 

 

J.

INTEREST, DIVIDENDS, ROYALTIES

 

$

$

 

 

 

 

 

 

 

 

 

K.

RAILROAD RETIREMENT PENSION

 

$

$

 

 

 

 

 

 

 

 

 

L.

WORKER’S COMPENSATION

 

$

$

 

 

 

 

 

 

 

 

 

 

M.

AFDC PAYMENTS

 

 

$

$

 

 

 

 

 

 

 

 

 

 

N.

OTHER: (SPECIFY)

 

 

$

$

 

 

 

 

 

 

 

 

 

 

Page 3 of 4 pages

17.

HAVE YOU, YOUR SPOUSE OR YOUR PARENT(S) APPLIED FOR OR DO YOU EXPECT TO

 

 

FOR COUNTY USE ONLY

 

START RECEIVING INCOME FROM ANY OF THE SOURCES LISTED IN “ITEM 16”?

■ YES

■ NO

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

EXPECTED INCOME

 

 

 

 

 

 

 

TYPE OF INCOME

 

PLACE APPLIED

 

DATE APPLIED

 

DATE EXPECTED

How Verified:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. _____________________________

 

 

 

 

 

 

 

 

 

 

b. _____________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. _____________________________

18.

HAVE YOU, YOUR SPOUSE OR YOUR PARENTS HAD MEDICAL EXPENSES WITHIN THE LAST

■ YES

■ NO

 

 

 

 

3 MONTHS AND WANT MEDI-CAL FOR THOSE EXPENSES?

 

 

 

IN-KIND INCOME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

(A.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE ANY NON-CASH GIFTS OR

■ YES

■ NO

30-775.11

 

 

 

 

 

 

CONTRIBUTIONS OF RENT, FOOD, CLOTHING OR OTHER ITEMS OF NEED?

How Verified: ____________________

 

 

 

 

 

 

 

 

 

 

 

(B.) DO YOU, YOUR SPOUSE OR YOUR PARENT(S) RECEIVE NON-CASH COMPENSATION IN

■ YES

■ NO

_______________________________

 

RETURN FOR WORK?

 

 

 

 

 

 

(IF “YES” TO “(A)” OR “(B)”, GIVE THE INFORMATION BELOW:)

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

ITEM CONTRIBUTED

 

FREQUENCY OF

 

CASH EQUIVALENT

 

 

 

 

 

 

 

 

 

 

RECEIPT

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

_______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

PREMIUM PAYMENTS

 

 

 

 

 

 

 

 

 

 

 

20.

DO YOU, YOUR SPOUSE OR YOUR PARENT(S) HAVE HEALTH OR HOSPITALIZATION

■ YES

■ NO

Amount Paid: $ __________________

INSURANCE (INCLUDING PAID BY AN EMPLOYER)?

 

 

 

 

 

 

 

 

 

 

 

(IF “YES”, GIVE THE INFORMATION BELOW:)

 

 

 

 

 

How often: ______________________

 

 

 

 

 

 

 

 

 

 

 

INSURANCE CARRIER (CHECK APPLICABLE(S))

 

PERSON(S) INSURED

 

How Verified: ____________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ MEDICARE (CLAIM NO.

 

 

)

 

 

 

 

_______________________________

■ CHAMPUS

 

 

 

 

 

 

 

_______________________________

■ VETERAN’S ADMINISTRATION COVERAGE

 

 

 

 

 

 

 

 

 

 

_______________________________

■ KAISER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ ROSS—LOOS

 

 

 

 

 

 

 

_______________________________

■ BLUE SHIELD

 

 

 

 

 

 

 

 

 

 

■ BLUE CROSS

 

 

 

 

 

 

 

 

 

 

■ PREPAID HEALTH PLAN

 

 

 

 

 

 

 

 

 

 

■ HEALTH MAINTENANCE ORGANIZATION (SPECIFY:

)

 

 

 

 

 

 

 

■ OTHER CARRIER (SPECIFY:

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

ITEM NUMBER

 

ADDITIONAL INFORMATION (ATTACH ADDLTLONAL SHEETS IF NECESSARY)

 

SOC 310 VERIFICATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

■ ELIGIBLE

■ INELIGIBLE

 

 

 

 

 

 

 

 

 

 

REASON (IF INELIGIBLE):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOCIAL SERVICE WORKER:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BE SURE YOU HAVE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONS THAT APPLY TO YOU. READ THE FOLLOWING CAREFULLY BEFORE SIGNING:

I HEREBY STATE BY MY SIGNATURE THAT THE ANSWERS I HAVE GIVEN ARE CORRECT AND TRUE TO THE BEST OF MY KNOWLEDGE.

I AGREE TO TELL THE COUNTY DEPARTMENT OF SOCIAL SERVICES WITHIN 10 DAYS IF THERE ARE ANY CHANGES IN MY INCOME, POSSESSIONS. OR EXPENSES, OR IN THE NUMBER OF PERSONS IN MY HOUSEHOLD, OR IF ANY CHANGE OF ADDRESS. AND I AGREE TO MEET ALL OTHER RESPONSIBILITIES EXPLAINED IN THE “MEDI–CAL RESPONSIBILITIES CHECKLIST” I HAVE RECEIVED.

I UNDERSTAND THAT I MAY BE ASKED TO PROVE MY STATEMENTS, BUT THAT THE COUNTY IS REQUIRED BY LAW TO KEEP THEM CONFIDENTIAL.

I UNDERSTAND THAT IF I AM DISSATISFIED WITH ANY ACTIONS TAKEN BY THE COUNTY DEPARTMENT OF SOCIAL SERVICES, I HAVE THE RIGHT TO A STATE HEARING.

I UNDERSTAND THAT I MUST DISPOSE OF ANY EXCESS RESOURCES WITHIN A SIX–MONTH PERIOD IN THE CASE OF REAL PROPERTY AND WITHIN THREE MONTHS IN THE CASE OF PERSONAL PROPERTY AND REPAY ANY OVERPAYMENTS WITH THE PROCEEDS OF THE DISPOSED PROPERTY.

I UNDERSTAND THAT IF I AM ELIGIBLE FOR IHSS SERVICES, I WILL BE PROVIDED A MEDI–CAL CARD AT NO SHARE–OF–COST TO ME IF I PAY THE IHSS SHARE OF COST I AM OBLIGATED TO PAY.

I UNDERSTAND THAT FEDERAL AND STATE LAW REQUIRE THE RECOVERY OF ALL MEDI-CAL BENEFITS RECEIVED AFTER AGE 55 FROM THE ESTATE OF A MEDI–CAL BENEFICIARY IF THERE IS NO SURVIVING SPOUSE, MINOR CHILDREN, OR PERMANENTLY AND TOTALLY DISABLED CHILDREN.

I, THE UNDERSIGNED, DECLARE UNDER PENALTY OF PERJURY THAT THE FOREGOING STATEMENTS ARE TRUE AND CORRECT.

SIGNATURE OF APPLICANT

DATE

SIGNATURE OF WITNESS (REQUIRED IF APPLICANT

DATE

 

 

SIGNED BY MARK)

 

 

 

 

 

SIGNATURE OF PERSON ACTING FOR APPLICANT

DATE

SIGNATURE OF PERSON HELPING APPLICANT

DATE

(RELATIONSHIP: PARENT, GUARDIAN, CONSERVATOR)

 

COMPLETE FORM

 

 

 

 

 

 

 

 

 

Page 4 of 4 pages

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