MC 171 Form PDF Details

Are you looking for information about the MC 171 Form? This important document can be crucial to understanding your legal rights and responsibilities, so it's essential to make sure that you understand its requirements. In this blog post, we will discuss what a MC 171 Form is, which situations may require one, and all the key details you need to know. We'll also provide tips and advice on how to fill out a Mc 171 properly so that you don't have any problems come up in the future. So if you are ready, let's dive into all things related this purposeful piece of paperwork!

Form Name MC 171 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names you mc171 form, mc171 forms, mc 171 long term, care form facility

Form Preview Example

State of California—Health and Human Services AgencyDepartment of Health Care Services




Patient’s name (last)



Name of facility









Social security number



Address (number and street)










Level of care is SNF/ICF unless checked




ZIP code


here as board and care.














Medi-Cal ID number (taken from the Medi-Cal card)

Admission date (month/day/year)

A. Do you have Medicare Part A, Hospital Coverage?



B. Expected length of stay:

At least one full month after the month of admission Less than one full month after the month of admission

C. Medi-Cal is expected to pay over 50% of facility cost of care.

Yes, beginning with month of


, 20




No, other insurance, private pay, etc.


D. Current income (check all applicable boxes):

Supplemental Security Gold Checks

Social Security Green Checks

Other Income (i.e., railroad, military retirement, etc.)


E. Admission from:


Board and Care

Household of another

Acute Hospital—Home, B&C, other household immediately prior to acute

Acute Hospital—SNF/ICF immediately prior to acute

Acute Hospital extended stay—over 30 days

Another SNF/ICF

F. If known, enter your address prior to facility admission. If admitted from an acute hospital, enter your address prior to the acute hospital admission. (Do not give the acute hospital’s address.)

Address (number and street)



ZIP code

G. Signature of recipient or representative payee or family member/other:

Signature of recipient

Signature of Representative Payee

Phone number

If recipient’s signature cannot be obtained, please indicate reason in this space.

Signature of family member/other (Indicate your relationship to the recipient.)

Phone number




A. Reason for discharge:

Discharged to Acute Hospital Discharged to another SNF/ICF Discharged to residence/home of another Discharged to Board and Care Discharged to other

Discharge due to death

B.Date of discharge (month/day/year)

C.Medi-Cal ID number (taken from the Medi-Cal card)

D.Complete the forwarding address for discharges other than death:

Name of facility (if not discharged home)

Address (number and street)



ZIP code

Facility representative signature


MC 171 (05/07)

I. General Instructions

This form is to be used for each admission and discharge. Please do not use this form for Medi-Cal reauthorizations.

II.Admission Instructions


Prepare an original and two copies of this form for each SSI/SSP and/or Medi-Cal admission.



Send to your local social security office for recipients with aid codes 10, 20, and 60.


Send to the county welfare department (see attached list) for all other aid codes.

Copy 1:

Attach to the Treatment Authorization Request (TAR) and send to the Department of


Care Health Services, Medi-Cal field office in your area. It will be forwarded


by the Medi-Cal field office to the county welfare department.

Copy 2:

Retain for your file.

III.Discharge Instructions


Prepare an original and two copies of this form for each SSI/SSP and/or Medi-Cal discharge. Instead of completing a new form, use copy two of the form retained in your file as part of the admissions process. Complete Part III of the form (which becomes the original for the discharge process), and make two copies.


Original: Send to the Medi-Cal field office.

Copy 1: Send to the county welfare department (see attached list).

Copy 2: Retain for your file.

IV. Explanation of over 50% of cost of care mentioned in item II.C. of this form.

Cost of care is the daily charge per patient excluding any additional services rendered to the patient which are billed separately by other providers (i.e., ambulance, physician, pharmacy, etc.).

For example, if the daily rate is $30 per day, the monthly charge for a 30-day month would be $900. If a patient enters the facility during the month of January, and is expected to stay at least one full calendar month after the month of admission (through February), a “YES” response would be indicated for item II.C. if Medi-Cal is expected to pay over $450 of the $900 charge for February.

MC 171 (05/07)

How to Edit MC 171 Form Online for Free

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

Step 2: After you start the editor, you will notice the document made ready to be filled in. Apart from filling in various blank fields, you might also perform some other things with the file, namely writing custom text, modifying the initial text, inserting illustrations or photos, signing the form, and a lot more.

It is actually an easy task to finish the pdf using out helpful guide! Here's what you need to do:

1. Whenever filling in the mc171 form, make certain to incorporate all of the essential fields within the relevant section. It will help speed up the work, allowing for your information to be processed without delay and properly.

Stage no. 1 of completing care facility admission

2. The next step is usually to fill in these blank fields: D Current income check all, Supplemental Security Gold Checks, Social Security Green Checks, Other Income ie railroad military, None, G Signature of recipient or, Signature of recipient, Signature of Representative Payee, If recipients signature cannot be, Signature of family memberother, Phone number, III COMPLETE THIS PORTION ONLY FOR, If known enter your address prior, Address number and street, and City.

Filling out segment 2 in care facility admission

Lots of people often get some points incorrect while filling out Supplemental Security Gold Checks in this area. Ensure you read twice what you type in here.

3. This 3rd segment should also be rather simple, Discharged to residencehome of, Discharged to Board and Care, Discharged to other, Discharge due to death, Facility representative signature, D Complete the forwarding address, Name of facility if not discharged, Address number and street, City, Date, State, and ZIP code - all of these empty fields will have to be filled out here.

ZIP code, Discharged to Board and Care, and State of care facility admission

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