Mc371 Medi Cal Details

If you're looking for a reliable way to track your company's expenses, the Mc 371 form is a great option. This form can help you keep track of all your business-related spending, so you can stay within budget and file accurate tax returns. In this blog post, we'll provide an overview of the Mc 371 form and explain how to complete it. We'll also discuss some of the benefits of using this form to manage your company's expenses.

You will see details about the type of form you intend to fill out in the table. It can show you the time you'll need to fill out mc 371 form, exactly what parts you will need to fill in, and so on.

QuestionAnswer
Form NameMc 371 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdhcs members online, mc 371 medi cal, mc 371, form mc 371

Form Preview Example

State of California - Health and Human Services Agency

Department of Health Care Services

Additional Family Members Requesting Medi-Cal

u Applicant/Caretaker’s Name (First, Middle, Last)

Applicant/Caretaker’s Relationship to Child(ren)

 

 

 

 

 

 

 

 

 

Name on Birth Certiicate

Gender

 

 

Pregnant? q Yes q No

 

q Male q Female

Due date: _______________ # of babies_____

 

 

 

 

 

 

 

 

 

Social Security No.

 

Date of Birth

 

 

Medi-Cal Requested? q Yes q No

 

 

 

 

 

 

If Yes, provide Beneits Identiication Card # if you have it:

 

 

Month Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (City/State/Country)

 

 

U.S. Citizen or National? q Yes q No

 

 

 

 

 

 

If No, date arrived in the U.S.

 

 

 

 

 

 

 

 

 

Month Day Year

 

 

 

 

 

 

 

Does this person have a physical, mental, emotional or

Marital Status (check one):

developmental disability?

 

 

 

 

 

q Married q Single q Widowed q Divorced

q Yes. Date disability began:

 

q No

q Separated

 

 

 

 

 

 

 

 

 

 

County Use Only

Case name:

Case #

Worker #

Date:

Linkage

SSN

PREG

ID

Other

v Spouse/Other Parent’s Name (First, Middle, Last)

Relationship to Applicant/Caretaker

 

 

 

 

 

Linkage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name on Birth Certiicate

 

Gender

 

 

Pregnant? q Yes q No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SSN

 

 

q Male q Female

Due date:

 

 

 

# of babies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security No.

 

Date of Birth

 

 

Medi-Cal Requested? q Yes q No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PREG

 

 

 

 

 

 

If Yes, provide Beneits Identiication Card # if you have it:

 

 

 

 

 

 

 

 

 

 

 

 

Month Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (City/State/Country)

 

 

U.S. Citizen or National? q Yes

q No

 

 

 

 

 

 

 

 

 

 

 

 

 

ID

 

 

 

 

 

 

If No, date arrived in the U.S.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this person have a physical, mental, emotional

Marital Status (check one):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

or developmental disability?

 

 

 

 

q Married q Single q Widowed q Divorced

 

 

 

 

 

 

 

q Yes. Date disability began:

q No

q Separated

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

w Child’s Name: (First, Middle, Last) or “Unborn”

Relationship to Applicant/Caretaker

 

 

 

 

 

 

 

 

 

 

 

 

Name on Birth Certiicate

Gender

 

Pregnant? q Yes q No

 

 

 

 

 

 

q Male q Female

Due date:

 

 

 

# of babies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security No.

Date of Birth

 

Medi-Cal Requested? q Yes q No

 

_____ _____ ______

If Yes, provide Beneits Identiication Card # if you have it:

 

Month Day

Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth (City/State/Country)

 

U.S. Citizen or National? q Yes

q No

 

 

 

 

If No, date arrived in the U.S.

 

 

 

 

 

 

 

 

 

 

 

 

Month Day Year

 

 

 

 

 

 

 

 

 

 

 

Child living in home? q Yes q No

 

Child in school? q Yes q No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mother’s Name:

 

 

 

Father’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this child have a physical, mental, emotional or

Is either parent:

 

 

 

 

 

developmental disability?

 

 

 

q Deceased q Absent q Incapacitated

q Yes. Date disability began:

q No

q Unemployed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Linkage

SSN

PREG

ID

Medical Support? q Yes q No

q CW 2.1 Q q CW 2.1

qNot in home, 18-21 tax dependent

MC 371_07/09 (Replaces MC 321 HFP-AP and MC 210S-C)

Page 1 of 2

x

Is anyone currently covered by health/dental insurance or Medicare? q Yes q No

q DHCS 6155

 

 

 

 

 

If so, who?

 

 

 

 

 

OHC Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

y

Has anyone iled a lawsuit because of an accident or injury? q Yes q No

q DHCS 6268

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

z Do you or any family member want Medi-Cal to cover medical expenses in the last three months

q MC 210 A

 

 

 

 

 

and wish to apply for Medi-Cal? q Yes q No

 

 

 

 

 

Retroactive Coverage

 

List name(s):

Month(s) of coverage:

 

 

 

 

 

 

 

 

 

 

 

 

Month

Month

 

Month

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

 

 

2

3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you or any family member ever been in U.S. military service? q Yes q No

q CW 5

 

 

 

 

 

 

 

If Yes, who? Name(s):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The Medi-Cal program may share your information unless you check the box below:

 

 

 

 

 

 

 

 

 

 

 

•

We will share your child’s application with Healthy Families if your child no longer qualiies for free Medi-Cal in the future. If you

 

•

do not want us to share it, check here q

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

We will share your child’s application with Healthy Kids or similar county program if your child does not qualify for

 

 

 

 

full-scope Medi-Cal. If you do not want us to share it, check here q

Family Income: List the income of every person listed in this application. Include child support and spousal support received. (Use a separate line for each source of income.)

Name of person with Income

Source of Income

How often is income

How much is

Social Security No.

(Children who are in school do not have to list

(Job, social security,

received?

the income?

(Optional)

their income from a job.)

pension, etc.)

(Weekly, biweekly, monthly)

(Total gross

 

 

 

 

income)

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

Expenses: List the monthly expenses for all persons listed above.

Child Day Care or Disabled Dependent Care

For (child or dependent’s name):__________________________________________ Age: ______ Amount Paid: _____________

How Often?______________

For (child or dependent’s name):__________________________________________ Age: _______ Amount Paid: ____________

How Often? _____________

Court-ordered child support

Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________

Court-ordered spousal support

Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________

Please note that additional information about your property, income and/or resources may be required if applicable.

I certify that I have read and understand the information above. I also certify that the information I have given on this form is true and correct.

Signature_____________________________________________________________________ Date: ________________

MC 371_07/09 (Replaces MC 321 HFP-AP and MC 210S-C)

Page 2 of 2

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