Mc 371 Form PDF Details

Enrolling in Medi-Cal, California's Medicaid program, involves a variety of steps and documentation to ensure that all eligible family members receive the healthcare coverage they need. Among these various forms, the MC 371 operates as a crucial document for families looking to add additional members to their Medi-Cal coverage. This form, tailored by the Department of Health Care Services, requires detailed information about each family member being added, including their personal details, health status, and current medical coverage situation. It meticulously covers applicant information, the relationship to the children being added, Social Security numbers, date of birth, and a myriad of other personal and sensitive data crucial for processing. The form not only captures basic demographic information but delves into the specifics such as pregnancy status, the potential need for retroactive coverage, and the presence of any disabilities, encapsulating a holistic view of the applicant's medical and social situation. Furthermore, the MC 371 form takes a comprehensive look at the family's financial situation, including income and expenses, to facilitate a thorough evaluation process. It underscores the importance of accuracy and honesty in reporting, as the information provided will determine the health services available to added family members. With such detailed requirements, the MC 371 form stands as a vital step for families seeking to ensure comprehensive health coverage through the Medi-Cal program, highlighting the nuanced and personalized approach taken by the State of California towards healthcare enrollment.

QuestionAnswer
Form NameMc 371 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform mc 371, mc 371 instructions, additional family members, 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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Prepare the additional family members PDF by typing in the information required for every section.

mc 371 add a person spaces to complete

Fill in the Social Security No, Date of Birth, Month Day Year, MediCal Requested q Yes q No If, PREG, Place of Birth CityStateCountry, US Citizen or National q Yes q No, Month Day Year, Does this person have a physical, Marital Status check one q Married, Other, w Childs Name First Middle Last or, Relationship to ApplicantCaretaker, Linkage, and Name on Birth Certiicate Gender field with all the data asked by the software.

Filling out mc 371 add a person part 2

Make sure you highlight the essential data in the Mothers Name, Fathers Name, Does this child have a physical, Is either parent q Deceased q, MC Replaces MC HFPAP and MC SC, Medical Support q Yes q No q CW Q, and Page of part.

Completing mc 371 add a person stage 3

You'll need to define the rights and responsibilities of both parties in section x Is anyone currently covered by, q DHCS, If so who, OHC Code, y Has anyone iled a lawsuit, q DHCS, z Do you or any family member want, q MC A, and wish to apply for MediCal q, List names Months of coverage, Retroactive Coverage, Month Month Month, Have you or any family member, q CW, and If Yes who Names.

stage 4 to filling out mc 371 add a person

End by looking at the following sections and filling in the pertinent information: Name of person with Income, Source of Income Job social, How often is income received, How much is the income Total gross, Social Security No Optional, Expenses List the monthly, Child Day Care or Disabled, For child or dependents name Age, How Often, For child or dependents name Age, How Often, Courtordered child support Paid to, Courtordered spousal support Paid, Please note that additional, and I certify that I have read and.

Entering details in mc 371 add a person part 5

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