Mc 223 Form PDF Details

The MC 223 form is a comprehensive document designed by the State of California—Health and Human Services Agency, Department of Health Care Services, to gather extensive personal, medical, social, and educational information from applicants seeking Medi-Cal benefits. It serves as a supplemental statement to support the application process, providing a detailed account of the applicant's medical history, work history, daily living activities, and any other information relevant to determining their eligibility for such benefits. The form spans eight pages, covering everything from basic personal details, such as name, social security number, and contact information, to intricate questions about the applicant's health issues, treatments received, and their impact on the applicant's ability to work or perform daily tasks. Additionally, it inquires about any Social Security Disability or Supplemental Security Income Disability benefits the applicant might have applied for in the past two years, delving into the specifics of the application outcomes and any changes in the applicant’s medical condition since then. This form not only aids in capturing the necessary information to process Medi-Cal applications but also ensures that applicants provide a thorough account of their situation, thereby enabling a more accurate and fair assessment of their eligibility for benefits.

QuestionAnswer
Form NameMc 223 Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesmc382 form, form mc 382, form mc 223, form mc223

Form Preview Example

Page1of8

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

 

 

APPLICANT’S SUPPLEMENTAL STATEMENT

 

COUNTY USE ONLY

 

 

 

 

 

 

 

 

 

OF FACTS FOR MEDI-CAL

 

 

County Number/Aid Code/Case Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

—

—

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART I—PERSONAL INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1a.

Applicant name (Last, First, MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1b. Social Security number

 

1c. Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

—

—

 

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1d.

Other name(s) used (Last, First, MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

1e. Sex

1f. Height

 

1g. Weight

 

 

 

 

Home addressA

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑Male

Feet _______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑Female

Inches _____

 

Pounds _________

 

 

2a.

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2b.

Mailing address (if different)

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Daytime telephone number

 

 

 

 

Check if:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Best time to call

 

 

 

 

 

 

 

 

 

 

 

 

 

❑No Phone

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

❑Message Phone (

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4a.

Do you speak English?

4b.

Do you have an

 

If YES, interpreter’s name:

 

 

 

 

Best time to call

 

 

 

 

 

 

 

 

 

 

 

interpreter?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑Yes

 

If YES, go to Part II

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑Yes ❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑No

 

 

 

 

 

 

 

 

 

 

 

Interpreter’s phone number:

 

 

 

 

 

 

 

 

 

If NO, what language(s) do you speak:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PART II—MEDICAL INFORMATION

COUNTY USE ONLY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Have you applied for Social Security Disability or Supplemental Security Income (SSI) Disability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

benefits in the past two (2) years?

❑ Yes ❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, please answer the following:

 

 

P

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a.Was/Is your Social Security or SSI Disability application:

 

❑Approved?

❑Denied?

❑ Pending?

❑ On Appeal?

❑Unknown?

 

 

 

 

b.

Ifapprovedordenied,givethedateofthemostrecentdecisiononyourSocialSecurityorSSIdisability

 

application:

 

 

 

 

L

 

 

_________________________________________________________________________________

 

c.

Has your medical problem(s) worsened since the date in 5b above?

 

Yes

❑ No

 

 

 

 

 

If YES, please explain:

______________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

_____________________________________________________________________________________________

 

 

d.Do you have any NEW medical problem(s) since the date in 5b, above, which you did NOT have when your Social Security or SSI disability decision was made?

❑ Yes ❑ No

If YES, what medical problem(s)? _________________________________________

_____________________________________________________________________________________________

6. List all medical problems (physical, mental or emotional) that keep you from working or taking care of your personal needs. (Please attach additional sheet, if necessary.)

MEDICAL PROBLEM(S)

E

WHEN DID IT

START (Month/Year)

 

 

 

 

 

 

 

 

 

 

 

 

 

MC223 (05/07)

7. Have you received care in a clinic or hospital for your illness(es) or injury(ies) in the last

 

COUNTY USE ONLY

 

 

 

 

 

 

 

12 months?

❑ Yes

❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, please fully answer the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of clinic/hospital

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient/clinic or member number

 

 

Clinic/hospital telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of doctor(s) seen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 220 Signed

 

 

 

ADDRESS of clinic/hospital (number, street, suite)

 

 

City

 

 

 

 

 

State

ZIP code

 

 

❑

 

 

 

A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date first seen

 

Date last seen

 

 

 

 

 

 

 

Date of next appointment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Reason for the visit(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you stay in the hospital overnight?

❑ Yes

❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, date(s) entered:

 

_______________________________ date(s) left: ______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you seen in the emergency room?

❑ Yes

❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, date(s) seen:

_______________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List ALL medicines received:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

______________________________________________________________________

 

 

 

 

 

 

 

 

_____________________________________________________________________________________________________

 

 

 

 

 

 

 

List ALL treatments received and the dates the treatments were received:

_____________________

 

 

 

 

 

 

 

 

__________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

8. List any additional clinic or hospital where you have been seen in the last 12 months.

 

 

 

 

 

 

 

Name of clinic/hospital

 

 

 

 

 

 

 

 

 

 

P

 

 

 

 

 

 

 

 

Patient/clinic or member number

 

 

Clinic/hospital telephone number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of doctor(s) seen

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 220 Signed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

❑

 

ADDRESS of clinic/hospital (number, street, suite)

 

 

City

 

 

 

 

 

State

ZIP code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date first seen

 

 

 

 

 

 

 

Date last seen

 

 

 

 

 

 

 

Date of next appointment

 

 

 

 

 

 

 

Reason for the visit(s)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did you stay in the hospital overnight?

❑ Yes

❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, date(s) entered:

_______________________________ date(s) left: ________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were you seen in the emergency room?

❑ Yes

❑ No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If YES, date(s) seen:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

_______________________________________________________________________________

 

 

 

 

 

 

 

List ALL medicines received:

______________________________________________________________________

 

 

 

 

 

 

 

_____________________________________________________________________________________________________

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

List ALL treatments received and the dates the treatments were received:

________________________

 

 

 

 

 

 

 

_____________________________________________________________________________________________________

 

 

 

 

 

 

If you have been seen at additional clinics or hospitals in the last 12 months, complete page 8.

MC 223 (05/07)

Page 2 of 8

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When it comes to fields of this particular PDF, this is what you should consider:

1. While filling in the form mc382, ensure to complete all of the needed blanks in its relevant part. It will help speed up the work, allowing for your details to be handled fast and properly.

Step number 1 for completing mc 382 spanish

2. Immediately after the first section is done, go to type in the suitable information in all these - a WasIs your Social Security or, Approved Denied Pending On, If approved or denied give the, application, c Has your medical problems, If YES please explain, d Do you have any NEW medical, your Social Security or SSI, If YES what medical problems, List all medical problems, Please attach additional sheet if, MEDICAL PROBLEMS, WHEN DID IT, START MonthYear, and Page of Page of.

Step # 2 in submitting mc 382 spanish

Regarding a WasIs your Social Security or and START MonthYear, be certain you get them right here. Both these could be the most significant ones in this PDF.

3. Completing Have you received care in a, months Yes No, COUNTY USE ONLY, If YES please fully answer the, Name of clinichospital, Patientclinic or member number, Clinichospital telephone number, ADDRESS of clinichospital number, Name of doctors seen, Reason for the visits, Did you stay in the hospital, Date first seen, Date last seen, Date of next appointment, and City is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

How one can fill out mc 382 spanish part 3

4. The following subsection will require your attention in the following areas: List ALL medicines received, List ALL treatments received and, List any additional clinic or, Name of clinichospital, Patientclinic or member number, Name of doctors seen, Clinichospital telephone number, ADDRESS of clinichospital number, City, Date first seen, Date last seen, Reason for the visits, Did you stay in the hospital, ZIP code, and MC Signed. Just be sure you enter all of the required information to move further.

Clinichospital telephone number, City, and List ALL treatments received and inside mc 382 spanish

5. This very last section to complete this PDF form is pivotal. Make certain to fill in the displayed blank fields, consisting of If YES dates entered dates left, If YES dates seen, List ALL medicines received, List ALL treatments received and, If you have been seen at, in the last months complete page, and Page of, before finalizing. If you don't, it may end up in an unfinished and probably unacceptable form!

Stage no. 5 for filling out mc 382 spanish

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