Mc216 Medical Renewal Form PDF Details

The Mc216 medical renewal form is used to renew medical certification for aviation personnel. The form must be completed and signed by a certified physician in order to renew medical certification. The form can be downloaded from the Federal Aviation Administration's website, and instructions for completing the form are included. A valid email address is required in order to download the form.

Here is the data in regards to the form you were looking for to fill in. It will tell you the length of time you will need to complete mc216 medical renewal form, what fields you will have to fill in, etc.

QuestionAnswer
Form NameMc216 Medical Renewal Form
Form Length97 pages
Fillable?No
Fillable fields0
Avg. time to fill out24 min 15 sec
Other namesmc 216 renewal form pdf, mc renewal mc 216, mc 216 english, mc 0216

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State of California—Health and Human Services Agency

Department of Health Care Services

JENNIFER KENT

EDMUND G. BROWN JR.

Director

Governor

May 19, 2015

 

Medi-Cal Eligibility Division Information Letter No.: I 15-14

TO:

ALL COUNTY WELFARE DIRECTORS

 

ALL COUNTY WELFARE ADMINISTRATIVE OFFICERS

 

ALL COUNTY MEDI-CAL PROGRAM SPECIALISTS/LIAISONS

SUBJECT:

Revised MC 216 Pre-Populated Renewal Form

 

(Reference: All County Welfare Directors Letter 15-09 and

 

14-38)

The purpose of this letter is to transmit the revised MC 216 Pre-Populated Renewal Form to counties, which is used to confirm and request verification of beneficiary information known to the California Healthcare Eligibility, Enrollment, and Retention System and the Statewide Automated Welfare Systems at annual renewal. Attached with this letter is a copy of the updated MC 216 form (Rev 04/15) in all threshold languages for counties to implement within 90 days from the receipt of this letter.

The single change to the form is specific to Section 3 titled “Income and Expenses” on Page 3, subsection “Fluctuating Income”, the question “What do you think your income will be for the next 12 months?” has been replaced with “Tell us what you think your income will be for the current calendar year?”.

If you have any questions regarding this letter, please contact Deborah Palmer at

(916)440-7855 or by email at deborah.palmer@dhcs.ca.gov or Michelle Marean-Williams at (916) 341-3968 or by email at michelle.marean-williams@dhcs.ca.gov. We appreciate the counties’ cooperation and assistance in this effort.

Original Signed By

Alice Mak, Acting Chief

Medi-Cal Eligibility Division

Attachments

Medi-Cal Eligibility Division

1501 Capitol Avenue, MS 4607, P.O. Box 997417, Sacramento, CA 95899-7417

(916)552-9430 phone, (916) 552-9477 fax Internet Address: www.dhcs.ca.gov

Medi-Cal Renewal Form

Respond By: [MM/DD/YY]

Case Number: [xxxxxxxxx]

[Insert Date]

 

 

You can get this notification in another language or in large print or another way that’s best for you. Call [1-800-XXX-XXXX]. The call is free. [(TTY: 1-888-XXX-XXXX)].

It is time to renew your Medi-Cal coverage. We need some information from you to help you keep your Medi-Cal for the next year.

You Can Renew Your Medi-Cal in Any One of These Ways

By Mail: Complete this form and mail it to:

Online: renewing nline is quick and easy. Go to

[Medicaid agency]

www.coveredca.c m [saWs online portal]

[100 state street]

to upload your d cuments.

[any city, state]

Purposes

 

In Person: Visit our office at

[Medicaid agency] [100 state street] [any city, state].

Office hours are [8:30 a.m. to 5 p.m. Monday to Friday].

 

How to Complete this Form

 

 

 

 

 

 

 

 

 

Informational

ge, you must let us know if there are any changes or not to

 

to make sure you or your family continue to have Medi-C l cover

 

the information on this form.

 

 

 

1.

Please review the information about you and members of

3.

return this form or provide this information online by

 

 

your household and let us know about any cha ges.

 

[Insert Date].

 

2.

send us or upload copies of documen s hat sh w y ur most

4.

If you return this form by mail, please make sure to sign

 

 

current information even if your inform ion h s not changed.

 

the form on page [Insert PaGe #].

Whose Information We Need

We need the most current inf

ation about every member of your household who is living with you or is listed on your tax

return, if you file taxes. We need information from:

 

People in your h useh ld who currently have Medi-Cal,

apply for Medi-Cal. their information will be kept private

People in your household who would like to apply.

and used only to help those in your household who want

to keep or apply for Medi-Cal.

 

We may eed some information about people in your

 

 

household who live with you

are listed on your tax

You do not need to file a tax return to apply for or renew

 

etu n, who do not have Medi-Cal and who do not want to

your Medi-Cal.

What Happens if My Information is Different?

If anyone in your household does not qualify for Medi-Cal because the information on this form has changed, we will use your new information to check to see if you or other people in your household qualify for other affordable health coverage, including Covered California. Your information

will be kept private and will be used only to see if you or your family qualifies for affordable health coverage. We may need more information from you to find you the most affordable health coverage. You do not need to file a tax return to apply for or renew your Medi-Cal.

Questions? Call [state agency name] at [1-800-XXX-XXXX]. The call is free. [(TTY: 1-888-XXX-XXXX)]. You can call [ days and hours of operation]. Or visit [web address]

MC 216 (Rev 04/15)

Page 1

For Informational Purposes Only

1Your Current Household

Please check the information below and tell us if there are any changes.

Is the address below correct?

Yes

If correct, go to Section 2.

 

[reCIPIent naMe] Home address: [aDDress 2] [Address 3]

Mailing address: [HOMe aDDress] [aDDress 2] [Address 3]

Phone:

Home: [nuMber1]

Other: [nuMber2]

no. If not, please write the correct information below.

name (first, middle, last & suffix)

 

Home address

apartment #

 

 

 

 

 

 

City (home)

state

ZIP code

 

 

 

 

Mailing address, only if different from above.

apartment #

 

 

 

 

City (mailing)

state

ZIP code

What number can we call to contact you? Home

Cell

Work

 

 

 

number:

 

 

 

 

 

What is the best time to reach you at this number?

 

 

 

 

 

(Optional) Is there another number we can use to call y

u?

Home Cell Work

 

 

 

number:

 

 

 

 

 

(Optional) What email address can we contact you?

 

 

2Who is in Your Household?

Please check the information below about people in your household who want to renew Medi-Cal. Please tell us if there are any changes to the information we have about people livi g with you or who are listed on your federal tax return.

Name (first, middle, last & suffix)

Tax Filing Status

How is this Person Related to the

Who Claims this Person Correct Information?

(e.g., primary tax filer, dependent)

Primary Tax Filer or Head of Household?

as a Dependant?

Yes

no

 

 

Yes

no

 

 

Yes

no

 

 

Yes

no

 

 

If the information above is ot correct, please write the correct information into the space provided below. If there are other members of your household, please write their information in below.

Name (first, middle, last & suffix)

Tax Filing Status

Related to Tax Filer

Who Claims this Person

 

 

 

as a Dependant?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2

For Informational Purposes Only

3Income and Expenses

We were not able to renew your Medi-Cal using the income below that we have for you or your household members from electronic data sources. Please let us know if the information below is correct or not. We need paper documentation showing us what your most current income is. Please attach any of the following that show income before taxes or deductions: recent pay stubs, benefits or award letters, checks received or signed statement from employer, or last year’s tax return. If income is from self-employment, send a copy of your most recent tax return or profit and loss statement.

the income information below is only for individuals within your household we could not otherwise verify. If you have members of your household not listed below it is because we were able to verify their income and no other income information is needed for the individual.

[Pre-Populated name:]

Our records show that this individual’s monthly income is:

 

.

this estimate includes the income sources and amounts below. Please let us know if this information is correct or has changed. If this information has changed, please tell us the correct information.

Income 1

 

 

 

 

How often received?

 

 

 

 

 

Is this correct?

Yes

no

If no, enter correct information

 

 

 

 

Income 2

 

 

 

How often received?

 

 

 

Is this correct?

Yes

no

If no, enter correct inf rmati n

 

 

Income 3

 

 

 

How often eceived?

 

Is this correct?

Yes

no

If no, enter co ect information

 

 

Please enter below any additional income you expect that is not shown above:

source of Income

amount

How Often received?

Informational

 

Fluctuating Income

 

 

You told us that your income changes from mon h m nth and gave us an estimate of what you thought your income would be for the

past 12 months. Last year, you told us your income would be

 

 

.

tell us what you think your income will be

the current calendar year?

 

 

Expenses/Tax Deductions

Our records show that this individual had the following tax expenses (deductions) last year. Please let us know if this will be the same for next year or not:

Tax Deduction 1

 

 

How often paid?

 

 

 

 

 

 

 

 

Is this correct?

Yes

no

If no, enter correct information

 

 

 

Tax Deduction 2

 

 

How often paid?

 

 

 

 

 

 

Is this co ect?

Yes

no

If no, enter correct information

 

 

Tax Deduction 3

 

 

How often paid?

 

 

Is this c rrect?

Yes

no

If no, enter correct information

 

 

Page 3

For Informational Purposes Only

Is this Individual Deceased?

4Other Health Insurance

Please let us know if the information below is still correct. If someone in your family now has other health insurance nOt listed below, please write it in below.

name

type of Insurance

Do You still Have this Coverage?

Yes no

Yes no

5Incarceration

Our information shows that one or more people in your household is incarcerated. Is this information correct?

name

Is this Individual Incarcerated?

 

 

Yes no

Yes no

6 Deceased

Our information shows that one more in your househo d has died. Is this information correct?

name

Yes no

Informational

Yes no

Page 4

For Informational Purposes Only

7Other Household Changes

Is anyone in your household between the ages of 18 and 26 years old and was either in foster care, in any state, on his or her 18th birthday or who lost foster care assistance, in any state, due to having reached the maximum age limit?

Yes

no If yes, who?

Is anyone in your household 19 to 20 years old and a full-time student?

Yes no If yes, who?

Does anyone in your household have a physical, mental, emotional, or developmental disability?

Yes no If yes, who?

Does anyone in your household need help with long-term care or home and community-based ervice ?

Yes no If yes, who?

Is anyone in your household pregnant?

Yes

no If yes, who?

 

 

 

 

 

 

 

 

If yes, what is her expected due date?

 

 

 

 

 

Informational

 

 

How many babies are expected?

 

 

 

 

 

 

Has anyone in your household moved into or out of the home in the p st 12 months?

 

 

Yes

no If yes, who?

 

 

 

 

 

 

What is your relationship to this person?

 

 

 

Do any of these individuals want to apply Medi-Cal?

 

 

Yes

no If yes, who?

 

 

 

 

 

 

If anyone in your household who cu

ently has Medi-Cal recently gained lawful immigration or citizenship status in the past 12 months,

list the name(s) below:

 

 

 

 

 

 

 

 

 

 

Name Pers

n (include first and last name)

New status

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 5

For Informational Purposes Only

8Signature

PRIVACY STATEMENT

RIGHTS AND RESPONSIBILITIES

This renewal form is for renewing benefits through the department

the information I gave on this renewal form is true as far as I know.

of Health Care services (dHCs) and determining eligibility for

I know that I may be subject to a penalty if I do not tell the truth.

health insurance through Covered California. the personal and

I understand that the information I give will be used only to see

medical information you provide on it is private and confidential.

if those in my family who are applying to renew hea th insurance

Covered California or DHCs needs it to identify you and the other

will qualify.

 

people on this renewal form and to administer our programs. We

 

 

 

 

will share your

information with other state, federal, and local

I understand that Covered California and the Medi-Cal program

agencies, contractors, health plans, and programs only to enroll

will keep my information private, as the law requires. For more

you in a plan or program or to administer programs, and with other

information, or access

to personal information in records

state and federal agencies as required by law.

 

Purposes

 

 

maintained by the Medi-Cal program and Covered California,

You must answer all of the questions on this renewal form unless

I can contact my county social ervices office or I can contact

the Covered California

Privacy Officer at 1-800-300-1506

they are marked “optional.” If your renewal form is missing anything

(TTY: 1-888-889-4500).

 

that we require, we will contact you to get it. If you do not provide it,

 

 

 

 

we will not be able to make a decision on your renewal. You may

I understand that to be eligible for Medi-Cal, I am required to

have to submit a new application, or you may not be able to get

apply for other inc me

benefits to which I or any member of

health insurance through Covered California, or your application

my household is entitled, unless he or she has good cause for

for benefits renewal may be denied.

not doing so. exam les of such income or benefits are pensions,

 

 

In most cases, you have the right to see personal information

government benefits, retirement income, veteran’s benefits,

about you that is in federal and state records. You can see it in

ann ities, disability benefits, social security benefits (also

an alternative format (such as large print) if you need that. For

called OAsdI or Old Age, survivors, and disability Insurance),

more information or to see Covered California records, contact the

and unemployment benefits. But such income or benefits do

Privacy Officer at:

not include public assistance benefits, such as CalWOrKs or

 

Informational

 

 

Covered California

Ca Fresh. If I have a question about a possible source of income,

I can call my county social services office or Covered California at

Attn: Privacy Officer

1-800-300-1506 (TTY: 1-888-889-4500) for help.

P.O. Box 989725

I know that I must tell Covered California or my Medi-Cal county

West sacramento, CA 95798-9725

Phone: 1-800-300-1506

social services office about changes to anything I stated in this

TTY: 1-888-889-4500

renewal form. to report changes, I can call my county social

For the Department of Health Care Services,

services office. Or I can call Covered California at 1-800-300-1506

(TTY: 1-888-889-4500) or visit CoveredCA.com.

contact the Information Protection unit t:

I know that Covered California or the Medi-Cal program must

P.O. Box 997413, Ms 4721

sacramento, Ca

not discriminate against me or anyone on this renewal form

95899-7413

 

because of race, color, national origin, religion, age, sex, sexual

Phone: 1-866-866-0602

orientation, marital status, veteran’s status, or disability. If I think

TTY: 1-877-735-2929

Covered California or the Medi-Cal program has discriminated

these state and federal laws give us the right to collect and keep

against me, including the failure to provide reasonable accom-

modations as required under state and federal law, I can make a

the information

the re ewal form: Covered Ca: 42 u.s.C. §

complaint by contacting the u.s. Department of Health & Human

18031; CA Gove nment Code §§ 100502(k) and 100503(a) dHCs:

services at www.hhs.gov/ocr/office/file or the California

CA Welfa e and Institutions Code § 14011 and Article 3, Chapters

Office of the Attorney General at http://oag.ca.gov/contact/

5 and 7, Parts 2 and 3, division 9. We must give you this Privacy

general-comment-question-or-complaint-form.

statement under CA Civil Code § 1798.17.

If I believe that Covered California or the Medi-Cal program has

You can find the Notices of Privacy Practices for the Medi-Cal

discriminated against me or anyone else on this renewal form in

program at www.dhcs.ca.gov and for Covered California at

connection with a Medi-Cal eligibility determination, I can also file

www.CoveredCA.com.

a complaint with the department of Health Care services, Office

 

 

of Civil rights by calling 1-916-440-7370 (TTY: 1-916-440-7399).

Page 6

For Informational Purposes Only

I understand that any changes in my information or information

I know that I can find out how to appeal by calling 1-855-795-0634

of any member(s) in the applicant’s household may affect the

(TTY: 1-800-952-8349) for the Medi-Cal program or calling

eligibility of other members of the household.

 

 

1-800-300-1506 (TTY:1-888-889-4500) for Covered California

If applying for Medi-Cal, I confirm that no one applying for health

enrollees.

 

 

I know that I must file an appeal within 90 days of the decision. I

insurance on this renewal form is confined, after the disposition of

charges (judgment), in a jail, prison, or similar penal institution or

know that I can represent myself or have someone else represent

correctional facility.

 

 

 

 

 

me in my appeal, such as an authorized representative, a friend,

I understand that I must report income changes to my Medi-Cal

a relative, or a lawyer.

 

I know that if I need help, someone at Covered Ca ifornia, the

county social services office or Covered California because it may

affect the eligibility for Medi-Cal benefits or the amount of premium

Medi-Cal program, or the county social services office can explain

assistance (or tax credits) that I may be eligible to receive. I

my case to me.

 

 

also understand if I receive too much premium assistance (or

DECLARATION

 

 

tax credits) during the benefit year, I will have to repay the extra

 

 

premium assistance back to the Irs when I file my federal income

I declare under penalty of perjury under the laws of the state of

taxes for the benefit year.

 

 

 

 

 

California that what I say below is true and correct.

I give my permission to the Medi-Cal program or Covered California

I understood all questions on this n

wal form and gave true and

to check other agencies’ computer records to verify citizenship,

correct answers as far as I know. Wh

re I did not know the answer

satisfactory immigration status, tax information, and other

myself, I made every rea onable att

mpt to confirm the answer

information related only to eligibility to see if I and other people on

with someone who did kn w.

 

this renewal form qualify for health insurance. If someone on the

I know that if I do n

t tell the truth on this renewal form, there may

renewal form qualifies for Medi-Cal:

 

 

 

I know that if Medi-Cal pays for a medical expense, any money I

be a civil or c iminal

enalty for perjury that may include up to four

years in jail. (see California Penal Code section 126.)

or anyone on this renewal form get from other health insurance

I know that the information in this renewal form will be used to

or legal settlements related to that expense will go to Medi-Cal

as payment for the expense until the expense is paid in full. For

decide if the people who are applying qualify for health insurance.

parents whose child or children qualify for Medi-Cal:

the Medi-Cal program and Covered California will keep the

 

 

 

 

 

 

information private, as required by federal and California law.

I know I will be asked to help the agency that collects medic

Purposes

I agree to notify the Medi-Cal program or my Medi-Cal

support from any parent

this renewal

who does not live

with the child and does not send support

the child. If I thi k

county social services offices or Covered California by

that helping will harm me

my children, can tell the Medi-Cal

calling 1-800-300-1506 (TTY: 1-888-889-4500) or visiting

program and I will not have to help.

 

 

 

CoveredCa.com if anything changes on this renewal form

Your right to appeal: If

 

think

Covered

Cal forn a or the

for any person applying for health insurance.

 

 

 

 

Medi-Cal program has made

mistake, c

ppe

l i s decision.

 

 

 

to appeal means to tell someone

Covered C

lifornia or the

 

 

 

Medi-Cal program that think its decision is wrong and ask for

 

 

 

a fair review of the action.

 

 

 

 

 

 

 

 

signature of applicant or auth

rized representative

 

 

 

Date and Place:

 

 

 

 

 

 

 

 

signature: Informational

Page 7

For Informational Purposes Only

Medi-Cal Renewal Form Respond By: [MM/DD/YY] Case Number: [xxxxxxxxx]

[Insert Date]

You can get this notification in another language or in large print or another way that’s best for you. Call [1-800-XXX-XXXX]. The call is free. [(TTY: 1-888-XXX-XXXX)].

It is time to renew your Medi-Cal coverage. We need some information from

 

 

 

Purposes

you to help you keep your Medi-Cal for the next year.

 

You Can Renew Your Medi-Cal in Any One of These Ways

 

 

By Mail: Complete this form and

 

Office hours are [8:30 a.m. to

 

mail it to:

 

5 .m. Monday to Friday].

 

[Medicaid agency]

Online: renewing online is quick

 

[100 state street]

 

 

and easy. Go to

 

[any city, state]

 

 

 

 

 

 

Informational

www.coveredca.com

 

In Person: Visit our office at

 

or [saWs online portal]

 

[Medicaid agency]

 

to upload your documents.

 

[100 state street]

 

 

 

 

[any city, state]

 

 

 

How to Complete this Form

to make sure y u or your family continue to have Medi-Cal coverage, you must let us kn w if there are any changes or not to the information

on this

.

 

1. Please review the information

2. send us or upload copies of

ab ut you and members of your

documents that show your most

h usehold and let us know about

current information even if your

any changes.

information has not changed

Continued on next page

Questions? Call [state agency name] at [1-800-XXX-XXXX]. The call is free. [(TTY: 1-888-XXX-XXXX)]. You can call [ days and hours of operation]. Or visit [web address]

MC 216 (Rev 04/15)

Page 1

 

For Informational Purposes Only

How to Complete this Form - Continued from page 1

3.return this form or provide this information online by [Insert Date].

4.If you return this form by mail, please make sure to sign the form on page [INSERT PAGE #].

Whose Information We Need

We need the most current information about every member of your household who is living with you or is listed on your tax return, if you file taxes. We need information from:

People in your household who

have Medi-Cal and who do not

currently have Medi-Cal,

want to apply for Medi-Cal. Their

People in your household who

informati n will be kept private and

used only to help those in your

would like to apply.

household who want to keep or

 

We may need some information

apply for Medi-Cal.

about people in your household

You do not need to file a tax return

who live with you or are listed

What Happens if My Informa n is Different?

on yourInformationaltax return, who do not to apply for or renew your Medi-Cal.

If anyone in your household does

kept private and will be used only to

not qualify for Medi-C l because

see if you or your family qualifies for

the information on this form has

affordable health coverage. We may

changed, we will use your new

need more information from you to

information to check to see if you

find you the most affordable health

or other people in your household

coverage. You do not need to file a

qualify

other affordable health

tax return to apply for or renew your

cove age, including Covered

Medi-Cal.

Calif rnia. Your information will be

 

Questions? Call [state agency name] at [1-800-XXX-XXXX]. The call is free. [(TTY: 1-888-XXX-XXXX)]. You can call [ days and hours of operation]. Or visit [web address]

MC 216 (Rev 04/15)

Page 2

 

For Informational Purposes Only

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mc 216 renewal form pdf gaps to complete

Within the area You Can Renew Your MediCal in Any, By Mail Complete this form and, Medicaid agency state street any, In Person Visit our office at, Online renewing online is quick, How to Complete this Form to make, Please review the information, return this form or provide this, Insert Date, send us or upload copies of, If you return this form by mail, the form on page Insert PaGe, and Whose Information We Need We need write down the data that the program demands you to do.

Entering details in mc 216 renewal form pdf step 2

Write down the crucial details in Whose Information We Need We need, People in your household who, People in your household who would, We may need some information, apply for MediCal their, You do not need to file a tax, What Happens if My Information is, will be kept private and will be, Questions Call state agency name, MC Rev, Page, For Informational For Informational, and Purposes Only Purposes Only section.

Filling in mc 216 renewal form pdf stage 3

The Is the address below correct If, Yes, no If not please write the correct, reCIPIent naMe, Home address, aDDress, Address, Mailing address, HOMe aDDress, aDDress, Address, Phone, Home nuMber, Other nuMber, and name first middle last suffix field has to be applied to list the rights or obligations of both sides.

Entering details in mc 216 renewal form pdf stage 4

Finish the document by taking a look at the next fields: Name first middle last suffix, Tax Filing Status, How is this Person Related to the, Who Claims this Person Correct, eg primary tax filer dependent, as a Dependant, Yes, Yes, Yes, Yes, If the information above is not, Name first middle last suffix, Tax Filing Status, Related to Tax Filer, and Who Claims this Person as a.

Filling in mc 216 renewal form pdf part 5

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