The Mc216 medical renewal form is used to renew medical certification for aviation personnel. The form must be completed and signed by a certified physician in order to renew medical certification. The form can be downloaded from the Federal Aviation Administration's website, and instructions for completing the form are included. A valid email address is required in order to download the form.
Here is the data in regards to the form you were looking for to fill in. It will tell you the length of time you will need to complete mc216 medical renewal form, what fields you will have to fill in, etc.
Question | Answer |
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Form Name | Mc216 Medical Renewal Form |
Form Length | 105 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 26 min 15 sec |
Other names | mc 0216 form printable english, mc 216 form, mc renewal mc 216, mc216 form |
State of
Department of Health Care Services
JENNIFER KENT |
EDMUND G. BROWN JR. |
Director |
Governor |
May 19, 2015
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TO: |
ALL COUNTY WELFARE DIRECTORS |
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ALL COUNTY WELFARE ADMINISTRATIVE OFFICERS |
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ALL COUNTY |
SUBJECT: |
Revised MC 216 |
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(Reference: All County Welfare Directors Letter |
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The purpose of this letter is to transmit the revised MC 216
The single change to the form is specific to Section 3 titled “Income and Expenses” on Page 3, subsection “Fluctuating Income”, the question “What do you think your income will be for the next 12 months?” has been replaced with “Tell us what you think your income will be for the current calendar year?”.
If you have any questions regarding this letter, please contact Deborah Palmer at
(916)
Original Signed By
Alice Mak, Acting Chief
Attachments
1501 Capitol Avenue, MS 4607, P.O. Box 997417, Sacramento, CA
(916)
Respond By: [MM/DD/YY] |
Case Number: [xxxxxxxxx] |
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[Insert Date] |
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You can get this notification in another language or in large print or another way that’s best for you. Call
It is time to renew your
You Can Renew Your
■ By Mail: Complete this form and mail it to: |
■ Online: renewing nline is quick and easy. Go to |
[Medicaid agency] |
www.coveredca.c m [saWs online portal] |
[100 state street] |
to upload your d cuments. |
[any city, state] |
Purposes |
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■In Person: Visit our office at
[Medicaid agency] [100 state street] [any city, state].
Office hours are [8:30 a.m. to 5 p.m. Monday to Friday].
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How to Complete this Form |
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Informational |
ge, you must let us know if there are any changes or not to |
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to make sure you or your family continue to have |
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the information on this form. |
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Please review the information about you and members of |
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return this form or provide this information online by |
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your household and let us know about any cha ges. |
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[Insert Date]. |
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2. |
send us or upload copies of documen s hat sh w y ur most |
4. |
If you return this form by mail, please make sure to sign |
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current information even if your inform ion h s not changed. |
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the form on page [Insert PaGe #]. |
Whose Information We Need
We need the most current inf |
ation about every member of your household who is living with you or is listed on your tax |
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return, if you file taxes. We need information from: |
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■ |
People in your h useh ld who currently have |
apply for |
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■ People in your household who would like to apply. |
and used only to help those in your household who want |
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to keep or apply for |
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We may eed some information about people in your |
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household who live with you |
are listed on your tax |
You do not need to file a tax return to apply for or renew |
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etu n, who do not have |
your |
What Happens if My Information is Different?
If anyone in your household does not qualify for
will be kept private and will be used only to see if you or your family qualifies for affordable health coverage. We may need more information from you to find you the most affordable health coverage. You do not need to file a tax return to apply for or renew your
Questions? Call [state agency name] at
MC 216 (Rev 04/15) |
Page 1 |
For Informational Purposes Only
1Your Current Household
Please check the information below and tell us if there are any changes.
Is the address below correct? |
Yes |
If correct, go to Section 2. |
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[reCIPIent naMe] Home address: [aDDress 2] [Address 3]
Mailing address: [HOMe aDDress] [aDDress 2] [Address 3]
Phone:
Home: [nuMber1]
Other: [nuMber2]
no. If not, please write the correct information below.
name (first, middle, last & suffix)
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Home address |
apartment # |
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City (home) |
state |
ZIP code |
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Mailing address, only if different from above. |
apartment # |
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City (mailing) |
state |
ZIP code |
What number can we call to contact you? Home |
Cell |
Work |
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number: |
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What is the best time to reach you at this number? |
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(Optional) Is there another number we can use to call y |
u? |
Home Cell Work |
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number: |
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(Optional) What email address can we contact you? |
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2Who is in Your Household?
Please check the information below about people in your household who want to renew
Name (first, middle, last & suffix)
Tax Filing Status |
How is this Person Related to the |
Who Claims this Person Correct Information? |
(e.g., primary tax filer, dependent) |
Primary Tax Filer or Head of Household? |
as a Dependant? |
Yes |
no |
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Yes |
no |
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Yes |
no |
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Yes |
no |
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If the information above is ot correct, please write the correct information into the space provided below. If there are other members of your household, please write their information in below.
Name (first, middle, last & suffix) |
Tax Filing Status |
Related to Tax Filer |
Who Claims this Person |
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as a Dependant? |
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Page 2
For Informational Purposes Only
3Income and Expenses
We were not able to renew your
the income information below is only for individuals within your household we could not otherwise verify. If you have members of your household not listed below it is because we were able to verify their income and no other income information is needed for the individual.
Our records show that this individual’s monthly income is: |
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this estimate includes the income sources and amounts below. Please let us know if this information is correct or has changed. If this information has changed, please tell us the correct information.
Income 1 |
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How often received? |
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Is this correct? |
Yes |
no |
If no, enter correct information |
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Income 2 |
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How often received? |
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Is this correct? |
Yes |
no |
If no, enter correct inf rmati n |
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Income 3 |
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How often eceived? |
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Is this correct? |
Yes |
no |
If no, enter co ect information |
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Please enter below any additional income you expect that is not shown above:
source of Income |
amount |
How Often received? |
Informational |
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Fluctuating Income |
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You told us that your income changes from mon h m nth and gave us an estimate of what you thought your income would be for the
past 12 months. Last year, you told us your income would be |
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tell us what you think your income will be |
the current calendar year? |
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Expenses/Tax Deductions
Our records show that this individual had the following tax expenses (deductions) last year. Please let us know if this will be the same for next year or not:
Tax Deduction 1 |
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How often paid? |
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Is this correct? |
Yes |
no |
If no, enter correct information |
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Tax Deduction 2 |
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How often paid? |
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Is this co ect? |
Yes |
no |
If no, enter correct information |
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Tax Deduction 3 |
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How often paid? |
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Is this c rrect? |
Yes |
no |
If no, enter correct information |
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Page 3
For Informational Purposes Only
4Other Health Insurance
Please let us know if the information below is still correct. If someone in your family now has other health insurance nOt listed below, please write it in below.
name |
type of Insurance |
Do You still Have this Coverage? |
Yes
no
Yes
no
5Incarceration
Our information shows that one or more people in your household is incarcerated. Is this information correct?
name |
Is this Individual Incarcerated? |
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Yes
no
Yes
no
6 Deceased
Our information shows that one more in your househo d has died. Is this information correct?
name
Yes no
Informational
Yes
no
Page 4
For Informational Purposes Only
7Other Household Changes
Is anyone in your household between the ages of 18 and 26 years old and was either in foster care, in any state, on his or her 18th birthday or who lost foster care assistance, in any state, due to having reached the maximum age limit?
Yes
no If yes, who?
Is anyone in your household 19 to 20 years old and a
Yes
no If yes, who?
Does anyone in your household have a physical, mental, emotional, or developmental disability?
Yes
no If yes, who?
Does anyone in your household need help with
Yes
no If yes, who?
Is anyone in your household pregnant?
Yes |
no If yes, who? |
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If yes, what is her expected due date? |
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Informational |
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How many babies are expected? |
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Has anyone in your household moved into or out of the home in the p st 12 months? |
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Yes |
no If yes, who? |
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What is your relationship to this person? |
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Do any of these individuals want to apply |
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Yes |
no If yes, who? |
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If anyone in your household who cu |
ently has |
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list the name(s) below: |
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Name Pers |
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Page 5
For Informational Purposes Only
8Signature
PRIVACY STATEMENT |
RIGHTS AND RESPONSIBILITIES |
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This renewal form is for renewing benefits through the department |
the information I gave on this renewal form is true as far as I know. |
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of Health Care services (dHCs) and determining eligibility for |
I know that I may be subject to a penalty if I do not tell the truth. |
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health insurance through Covered California. the personal and |
I understand that the information I give will be used only to see |
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medical information you provide on it is private and confidential. |
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if those in my family who are applying to renew hea th insurance |
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Covered California or DHCs needs it to identify you and the other |
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will qualify. |
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people on this renewal form and to administer our programs. We |
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will share your |
information with other state, federal, and local |
I understand that Covered California and the |
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agencies, contractors, health plans, and programs only to enroll |
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will keep my information private, as the law requires. For more |
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you in a plan or program or to administer programs, and with other |
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information, or access |
to personal information in records |
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state and federal agencies as required by law. |
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Purposes |
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maintained by the |
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You must answer all of the questions on this renewal form unless |
I can contact my county social ervices office or I can contact |
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the Covered California |
Privacy Officer at |
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they are marked “optional.” If your renewal form is missing anything |
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(TTY: |
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that we require, we will contact you to get it. If you do not provide it, |
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we will not be able to make a decision on your renewal. You may |
I understand that to be eligible for |
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have to submit a new application, or you may not be able to get |
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apply for other inc me |
benefits to which I or any member of |
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health insurance through Covered California, or your application |
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my household is entitled, unless he or she has good cause for |
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for benefits renewal may be denied. |
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not doing so. exam les of such income or benefits are pensions, |
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In most cases, you have the right to see personal information |
government benefits, retirement income, veteran’s benefits, |
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about you that is in federal and state records. You can see it in |
ann ities, disability benefits, social security benefits (also |
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an alternative format (such as large print) if you need that. For |
called OAsdI or Old Age, survivors, and disability Insurance), |
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more information or to see Covered California records, contact the |
and unemployment benefits. But such income or benefits do |
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Privacy Officer at: |
not include public assistance benefits, such as CalWOrKs or |
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Informational |
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Covered California |
Ca Fresh. If I have a question about a possible source of income, |
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I can call my county social services office or Covered California at |
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Attn: Privacy Officer |
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P.O. Box 989725 |
I know that I must tell Covered California or my |
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West sacramento, CA |
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Phone: |
social services office about changes to anything I stated in this |
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TTY: |
renewal form. to report changes, I can call my county social |
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For the Department of Health Care Services, |
services office. Or I can call Covered California at |
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(TTY: |
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contact the Information Protection unit t: |
I know that Covered California or the |
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P.O. Box 997413, Ms 4721 |
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sacramento, Ca |
not discriminate against me or anyone on this renewal form |
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because of race, color, national origin, religion, age, sex, sexual |
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Phone: |
orientation, marital status, veteran’s status, or disability. If I think |
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TTY: |
Covered California or the |
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these state and federal laws give us the right to collect and keep |
against me, including the failure to provide reasonable accom- |
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modations as required under state and federal law, I can make a |
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the information |
the re ewal form: Covered Ca: 42 u.s.C. § |
complaint by contacting the u.s. Department of Health & Human |
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18031; CA Gove nment Code §§ 100502(k) and 100503(a) dHCs: |
services at www.hhs.gov/ocr/office/file or the California |
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CA Welfa e and Institutions Code § 14011 and Article 3, Chapters |
Office of the Attorney General at http://oag.ca.gov/contact/ |
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5 and 7, Parts 2 and 3, division 9. We must give you this Privacy |
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statement under CA Civil Code § 1798.17. |
If I believe that Covered California or the |
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You can find the Notices of Privacy Practices for the |
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discriminated against me or anyone else on this renewal form in |
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program at www.dhcs.ca.gov and for Covered California at |
connection with a |
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www.CoveredCA.com. |
a complaint with the department of Health Care services, Office |
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of Civil rights by calling |
Page 6
For Informational Purposes Only
I understand that any changes in my information or information |
I know that I can find out how to appeal by calling |
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of any member(s) in the applicant’s household may affect the |
(TTY: |
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eligibility of other members of the household. |
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If applying for |
enrollees. |
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I know that I must file an appeal within 90 days of the decision. I |
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insurance on this renewal form is confined, after the disposition of |
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charges (judgment), in a jail, prison, or similar penal institution or |
know that I can represent myself or have someone else represent |
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correctional facility. |
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me in my appeal, such as an authorized representative, a friend, |
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I understand that I must report income changes to my |
a relative, or a lawyer. |
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I know that if I need help, someone at Covered Ca ifornia, the |
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county social services office or Covered California because it may |
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affect the eligibility for |
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assistance (or tax credits) that I may be eligible to receive. I |
my case to me. |
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also understand if I receive too much premium assistance (or |
DECLARATION |
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tax credits) during the benefit year, I will have to repay the extra |
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premium assistance back to the Irs when I file my federal income |
I declare under penalty of perjury under the laws of the state of |
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taxes for the benefit year. |
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California that what I say below is true and correct. |
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I give my permission to the |
I understood all questions on this n |
wal form and gave true and |
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to check other agencies’ computer records to verify citizenship, |
correct answers as far as I know. Wh |
re I did not know the answer |
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satisfactory immigration status, tax information, and other |
myself, I made every rea onable att |
mpt to confirm the answer |
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information related only to eligibility to see if I and other people on |
with someone who did kn w. |
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this renewal form qualify for health insurance. If someone on the |
I know that if I do n |
t tell the truth on this renewal form, there may |
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renewal form qualifies for |
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I know that if |
be a civil or c iminal |
enalty for perjury that may include up to four |
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years in jail. (see California Penal Code section 126.) |
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or anyone on this renewal form get from other health insurance |
I know that the information in this renewal form will be used to |
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or legal settlements related to that expense will go to |
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as payment for the expense until the expense is paid in full. For |
decide if the people who are applying qualify for health insurance. |
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parents whose child or children qualify for |
the |
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information private, as required by federal and California law. |
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I know I will be asked to help the agency that collects medic |
Purposes |
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I agree to notify the |
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support from any parent |
this renewal |
who does not live |
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with the child and does not send support |
the child. If I thi k |
county social services offices or Covered California by |
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that helping will harm me |
my children, can tell the |
calling |
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program and I will not have to help. |
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CoveredCa.com if anything changes on this renewal form |
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Your right to appeal: If |
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think |
Covered |
Cal forn a or the |
for any person applying for health insurance. |
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mistake, c |
ppe |
l i s decision. |
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to appeal means to tell someone |
Covered C |
lifornia or the |
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a fair review of the action. |
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signature of applicant or auth |
rized representative |
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Date and Place: |
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signature: Informational
Page 7
For Informational Purposes Only
[Insert Date]
You can get this notification in another language or in large print or another way that’s best for you. Call
It is time to renew your |
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Purposes |
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you to help you keep your |
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You Can Renew Your |
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■ By Mail: Complete this form and |
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Office hours are [8:30 a.m. to |
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mail it to: |
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5 .m. Monday to Friday]. |
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[Medicaid agency] |
■ Online: renewing online is quick |
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[100 state street] |
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and easy. Go to |
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[any city, state] |
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Informational |
www.coveredca.com |
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■ In Person: Visit our office at |
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or [saWs online portal] |
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[Medicaid agency] |
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to upload your documents. |
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[100 state street] |
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[any city, state] |
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How to Complete this Form
to make sure y u or your family continue to have
on this |
. |
|
1. Please review the information |
2. send us or upload copies of |
|
ab ut you and members of your |
documents that show your most |
|
h usehold and let us know about |
current information even if your |
|
any changes. |
information has not changed |
Continued on next page
Questions? Call [state agency name] at
MC 216 (Rev 04/15) |
Page 1 |
|
For Informational Purposes Only
How to Complete this Form - Continued from page 1
3.return this form or provide this information online by [Insert Date].
4.If you return this form by mail, please make sure to sign the form on page [INSERT PAGE #].
Whose Information We Need
We need the most current information about every member of your household who is living with you or is listed on your tax return, if you file taxes. We need information from:
■ People in your household who |
have |
|
currently have |
want to apply for |
|
■ People in your household who |
informati n will be kept private and |
|
used only to help those in your |
||
would like to apply. |
||
household who want to keep or |
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|
||
■ We may need some information |
apply for |
|
about people in your household |
You do not need to file a tax return |
who live with you or are listed
What Happens if My Informa n is Different?
on yourInformationaltax return, who do not to apply for or renew your
If anyone in your household does |
kept private and will be used only to |
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not qualify for |
see if you or your family qualifies for |
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the information on this form has |
affordable health coverage. We may |
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changed, we will use your new |
need more information from you to |
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information to check to see if you |
find you the most affordable health |
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or other people in your household |
coverage. You do not need to file a |
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qualify |
other affordable health |
tax return to apply for or renew your |
cove age, including Covered |
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Calif rnia. Your information will be |
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Questions? Call [state agency name] at
MC 216 (Rev 04/15) |
Page 2 |
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For Informational Purposes Only