Mc 223 Form – Fill Out and Use This PDF

The MC 223 form serves as an Applicant's Supplemental Statement of Facts for Medi-Cal in California. This comprehensive document is utilized by the Health and Human Services Agency, Department of Health Care Services, to gather personal and medical information from applicants. It aids in determining eligibility for services by examining medical history, current health status, and work history. Interested individuals are encouraged to accurately complete the form to facilitate their application process. Click the button below to start filling out the form.

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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.

Question	Answer
Form Name	Mc 223 Form
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	mc382 form, form mc 382, form mc 223, form mc223

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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

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

❑Yes ❑ No

❑No

Interpreter’s phone number:

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

(

)

PART II—MEDICAL INFORMATION

COUNTY USE ONLY

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:

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

❑Approved?

❑Denied?

❑ Pending?

❑ On Appeal?

❑Unknown?

Ifapprovedordenied,givethedateofthemostrecentdecisiononyourSocialSecurityorSSIdisability

application:

_________________________________________________________________________________

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
MEDICAL PROBLEM(S)		START (Month/Year)
		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

❑

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:

_______________________________________________________________________________

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

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)

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:

______________________________________________________________________

_____________________________________________________________________________________________________

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

9. Have you been seen by any doctor outside of the clinic(s) or hospital(s) you have already		COUNTY USE ONLY
listed in the last 12 months?	❑ Yes ❑ No
listed in the last 12 months?	❑ Yes ❑ No

If NO, go to number 10. If YES, please fully answer the following, if more than one doctor was seen please complete page 8 for all additional information:

Name of doctor(s)

	Patient/clinic or member number			Doctor’s telephone number
				(	)
	Address of doctor (number, street, suite)			City		STate		ZIP code	MC 220 Signed
									❑
	Date first seen		Date last seen			Date of next appointment
	Reason for theAvisit(s)
	Reason for theAvisit(s)
	List ALL medicines received:	______________________________________________________________________
______________________________________________________________________________________________________
	List ALL treatments received and the dates the treatments were received:						________________________

	______________________________________________________________________________________________________

10.Please list below if you have had any of the following tests in the last 12 months. Be sure to check yesornonexttoeachtest.(IFADDRESSOFDOCTOR,CLINIC,ORHOSPITALWASGIVEN ALREADY, LIST ONLY THE NAME AND DATE.)

TEST	NAME AND ADDRESS OF OFFICE, CLINIC,	DATE
PERFORMED YES NO	OR HOSPITAL WHERE TEST WAS COMPLETED	(MO/YR)

	Name

Electrocardiogram					MC 220 Signed
	Address (number, street, suite)				MC 220 Signed
	Address (number, street, suite)
(EKG)					❑
	City	P	State	ZIP Code
	City		State	ZIP Code
	Name
Treadmill					MC 220 Signed
	Address (number, street, suite)				MC 220 Signed
	Address (number, street, suite)				❑
(exercise heart test)					❑
	City		State	ZIP Code
	City		State	ZIP Code

	Name

Chest X-ray					MC 220 Signed
	Address (number, street, suite)				MC 220 Signed
	Address (number, street, suite)				❑
					❑

	City		State	ZIP Code
	City		State	ZIP Code
	Name		L
Breathing Test			L		MC 220 Signed
	Address (number, street, suite)				MC 220 Signed
	Address (number, street, suite)				❑
(PFT)					❑
(PFT)
	City		State	ZIP Code
	City		State	ZIP Code

	Name

Blood Tests					MC 220 Signed
Blood Tests	Address (number, street, suite)				❑
					❑

	City		State	ZIP Code
	City		State	ZIP Code
	Name			E
Other				E	MC 220 Signed
Other	Address (number, street, suite)				MC 220 Signed
(Specify)					❑
	City		State	ZIP Code

MC 223 (05/07)

Page 3 of 8

11. Have you had any other medical treatment or testing in the past 12 months?	❑ Yes ❑ No	COUNTY USE ONLY

If NO, go to number 12.

If YES, complete page 8.

12.Is there anyone else (a friend, relative, social worker, rehab counselor, attorney, physical therapist, etc.) we may contact for information regarding your illness or injury and how it limits your daily activities or keeps you from working? ❑ Yes ❑ No

If YES, please list below:

Name	A

Address (number, street, suite)
Telephone number		Relationship to you

()

Name

Address (number, street, suite)

Telephone number			Relationship to you
(	)

Name		M
		M
Address (number, street, suite)

Telephone number			Relationship to you

()

13.You may be asked to go to additional medical examinations to help evaluate your medical problem(s). (These examinations are free to you.)

Are you willing to go to additional medical examinations if needed? ❑ Yes ❑ No

PART III—SOCIAL AND EDUCATIONAL INFORMATION

14.Describe your daily activities and tell us how much your condition limits your activities.

__________________________________________________________________________________________

15.Describe your educational background.

a.Check the highest grade you finished in school:

❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑ 8 ❑ 9 ❑ 10 ❑ 11

❑ 12 or ❑ GED (same as finishing 12th grade) ❑ 12+

b.When finished? Month/year: ________________________________

c.Did you take special education classes? ❑ Yes ❑ No

16.Have you done any type of work for more than 30 days during the last 15 years? (This includes work done in another country.)

❑ Yes ❑ No

If NO, skip Part IV, go to Part V, page 7, for your signature.

If YES, answer Part IV, page 5, beginning with number 17.

MC 223 (05/07)

Page 4 of 8

PART IV—WORK HISTORY

COUNTY USE ONLY

17. Describeallofthejobsyouhavedoneforatleast30daysduringthelast15years.Startwithyourmost

recent job. (If you had more than two jobs, ask your county worker for additional pages.)

Job title

Type of business

Dates worked (month/year)

Hours per week

Rate of pay

Per hour/wk/mo

From:

To:

DESCRIPTION OF THE JOB (This is what I did and how I did it.)

These are the tools, machines, and equipment I used:

I took this long to learn the job: _______________ day(s) or _______________ month(s).

I wrote, completed reports, or performed similar duties:			❑ Yes				❑ No
I had supervisory responsibilities:	❑ Yes ❑ No
I had supervisory responsibilities:	❑ Yes ❑ No

PHYSICAL ACTIVITY					Circle One

I walked this many hours in an average workday:		0		1	2	3	4	5	6	7	8
I stood this many hours in an average workday:		0		1	2	3	4	5	6	7	8
I sat this many hours in an average workday:		0		1	2	3	4	5	6	7	8

I climbed this much in an average workday:

❑ Never	❑ Occasionally ❑ Frequently	❑ Constantly

I bent over this much in an average workday:

		❑ Never	❑ Occasionally ❑ Frequently			❑ Constantly


Heaviest weight I lifted:			❑ 10 lbs	❑ 20 lbs	❑ 50 lbs	❑ Over 100 lbs
I often lifted/carried up to:			❑ 10 lbs	❑ 20 lbs	❑ 50 lbs	❑ Over 100 lbs

Did you have any of		your current medical		problem(s)	when you	performed this
job?	❑ Yes ❑ No

If NO, and you have had NO other jobs go to Part V, page 7, for your signature. If NO, but you have had other jobs, go to 17b, next page. If YES, please complete the following information.

Name of medical problem(s): ___________________________________________________________

Did your employer make special arrangements (such as extra breaks, special equipment, change in job duties, etc.) so you could continue to work? ❑ Yes ❑ No

If YES, describe the special arrangements made: ________________________________________

Did you have to stop working because of your medical problem(s)? ❑ Yes ❑ No

If YES, when? Month ____________________________________ Day _________ Year _________

Have you done any other work for more than 30 days during the last 15 years? ❑Yes ❑No If NO, go to Part V, page 7 for your signature. If YES, continue on 17b, next page.

MC 223 (05/07)

Page 5 of 8

17. b.	Job title		Type of business

	Dates worked (month/year)		Hours per week	Rate of pay	Per hour/wk/mo
	From:	To:

DESCRIPTION OF THE JOB (This is what I did and how I did it.)

These are the tools, machines, and equipment I used:

I took this long to learn the job: _______________ day(s) or _______________ month(s).

I wrote, completed reports, or performed similar duties:						Yes			No
I had supervisory responsibilities:		Yes	No
I had supervisory responsibilities:		Yes	No

PHYSICAL ACTIVITY						Circle One

I walked this many hours in an average workday:				0	1	2	3	4	5	6	7	8
I stood this many hours in an average workday:				0	1	2	3	4	5	6	7	8
I sat this many hours in an average workday:				0	1	2	3	4	5	6	7	8

I climbed this much in an average workday:

	Never		Occasionally			Frequently						Constantly

I bent over this much in an average workday:

	Never		Occasionally			Frequently						Constantly


Heaviest weight I lifted:			10 lbs		20 lbs			50 lbs				Over 100 lbs
I often lifted/carried up to:			10 lbs		20 lbs			50 lbs				Over 100 lbs

Did you have any of your current medical problem(s) when you performed this job? Yes No

If NO, and you have had NO other jobs go to Part V, page 7, for your signature. If NO, but you have had other jobs, ask your county worker for additional pages. If YES, please complete the following information.

Name of medical problem(s): ___________________________________________________________

Did your employer make special arrangements (such as extra breaks, special equipment, change

in job duties, etc.) so you could continue to work? Yes No

If YES, describe the special arrangements made: ________________________________________

Did you have to stop working because of your medical problem(s)?			Yes	No

If YES, when? Month	____________________________________	Day	_________	Year	________
Have you done any other work for more than 30 days during the last 15 years?

				Yes		No

If NO, go to Part V, page 7 for your signature. If YES, ask your county worker for additional pages to complete.

COUNTY USE ONLY

MC 223 (05/07)

Page 6 of 8

PART V—SIGNATURE AND CERTIFICATION

I declare under penalty of perjury under the laws of the United States of America and the State of California that the information contained in this Supplemental Statement of Facts is true and correct.

Signature of Applicant

Date

➧

Signature of Witness (If applicant signed with a mark)	Date
➧

Signature of person helping applicant fill out the form	Date
➧

You will need to sign an authorization for release of information for each clinic, hospital, and testing facility that you list and for each doctor you saw outside of a clinic or hospital. Your county worker will provide you with additional forms which you will need to sign.

MC 223 (05/07)

Page 7 of 8

	Continued answer(s) to question(s) number 8 on page 2, number 9 on page 3, and number 10 on page	COUNTY USE ONLY
	3. If you need more room, please ask your county worker for additional pages to complete.	COUNTY USE ONLY

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

Name of clinic/hospital

Patient/clinic or member number	Clinic/hospital telephone number
	(	)
Name of doctor(s) seen

City

State

ZIP code

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

MC 220 Signed

❑

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:

________________________________________________________________________

List ALL medicines received:

_______________________________________________________________________

______________________________________________________________________________________________________

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

________________________

______________________________________________________________________________________________________

List any additional doctor you saw outside of the clinic(s) or hospital(s) you have already listed:

Name of doctor(s)

Patient/clinic or member number

Doctor’s telephone number

(

)

Name of doctor(s) seen

ADDRESS of doctor (number, street, suite)

City

State

ZIP code

Date first seen

Date last seen

Date of next appointment

MC 220 Signed

Reason for the visit(s)

❑

List ALL medicines received:

________________________________________________________________

______________________________________________________________________________________________________

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

________________________

______________________________________________________________________________________________________

List any additional tests you have had in the last 12 months:

	NAME AND ADDRESS OF OFFICE, CLINIC, OR HOSPITAL				DATE
TEST PERFORMED		WHERE TEST(S) WAS COMPLETED.			(MO/YR)
	Name

	Address (number, street, suite)

	City	State	ZIP code	E

						MC 220 Signed
	Name					MC 220 Signed
						❑
	Address (number, street, suite)					❑



						MC 220 Signed
	City	State	ZIP code			MC 220 Signed
	City	State	ZIP code			❑
						❑

MC 223 (05/07)

Page 8 of 8

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

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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.

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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Mc 223 Form – Fill Out and Use This PDF

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