Question	Answer
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

	Medi-Cal Eligibility Division Information Letter No.: I 15-14
TO:	ALL COUNTY WELFARE DIRECTORS
	ALL COUNTY WELFARE ADMINISTRATIVE OFFICERS
	ALL COUNTY MEDI-CAL PROGRAM SPECIALISTS/LIAISONS
SUBJECT:	Revised MC 216 Pre-Populated Renewal Form
	(Reference: All County Welfare Directors Letter 15-09 and
	14-38)

Medi-Cal Renewal Form	Respond By: [MM/DD/YY]	Case Number: [xxxxxxxxx]
[Insert Date]

■ 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
	Purposes


How to Complete this Form
How to Complete this Form
	Informational	ge, you must let us know if there are any changes or not to
to make sure you or your family continue to have Medi-C l cover		ge, you must let us know if there are any changes or not to
the information on this form.
1.	Please review the information about you and members of	3.	return this form or provide this information online by
	your household and let us know about any cha ges.		[Insert Date].
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
	current information even if your inform ion h s not changed.		the form on page [Insert PaGe #].

We need the most current inf		ation 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 h useh ld who currently have Medi-Cal,		apply for Medi-Cal. their information will be kept private
■ People in your household who would like to apply.			and used only to help those in your household who want
■ People in your household who would like to apply.			to keep or apply for Medi-Cal.
	We may eed some information about people in your		to keep or apply for Medi-Cal.
■	We may eed some information about people in your
	household who live with you	are listed on your tax	You do not need to file a tax return to apply for or renew
	etu n, who do not have Medi-Cal and who do not want to		your Medi-Cal.

Is the address below correct?	Yes
If correct, go to Section 2.

Home address	apartment #

City (home)	state	ZIP code

Mailing address, only if different from above.		apartment #

City (mailing)	state	ZIP code

What number can we call to contact you? Home	Cell	Work

number:

What is the best time to reach you at this number?

(Optional) Is there another number we can use to call y	u?	Home Cell Work

number:

(Optional) What email address can we contact you?

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?

JENNIFER KENT	EDMUND G. BROWN JR.
Director	Governor

Income 1			How often received?
Is this correct?	Yes	no	If no, enter correct information
Income 2			How often received?
Is this correct?	Yes	no	If no, enter correct inf rmati n
Income 3			How often eceived?
Is this correct?	Yes	no	If no, enter co ect information

source of Income	amount	How Often received?
Informational
Fluctuating Income


past 12 months. Last year, you told us your income would be		.
tell us what you think your income will be	the current calendar year?

Name (first, middle, last & suffix)	Tax Filing Status	Related to Tax Filer	Who Claims this Person
			as a Dependant?

Tax Deduction 1			How often paid?
Tax Deduction 1			How often paid?
Is this correct?	Yes	no	If no, enter correct information
Is this correct?	Yes	no	If no, enter correct information
Tax Deduction 2			How often paid?
Tax Deduction 2			How often paid?
Is this co ect?	Yes	no	If no, enter correct information
Tax Deduction 3			How often paid?
Is this c rrect?	Yes	no	If no, enter correct information

Yes	no If yes, who?
If yes, what is her expected due date?
	Informational
How many babies are expected?
Has anyone in your household moved into or out of the home in the p st 12 months?
Yes	no If yes, who?
What is your relationship to this person?
Do any of these individuals want to apply Medi-Cal?
Yes	no If yes, who?
If anyone in your household who cu		ently has Medi-Cal recently gained lawful immigration or citizenship status in the past 12 months,
list the name(s) below:

	Name Pers	n (include first and last name)	New status

PRIVACY STATEMENT		RIGHTS AND RESPONSIBILITIES
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.
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.
health insurance through Covered California. the personal and		I understand that the information I give will be used only to see
medical information you provide on it is private and confidential.
		if those in my family who are applying to renew hea th insurance
Covered California or DHCs needs it to identify you and the other
		will qualify.
people on this renewal form and to administer our programs. We

will share your	information with other state, federal, and local	I understand that Covered California and the Medi-Cal program
agencies, contractors, health plans, and programs only to enroll
		will keep my information private, as the law requires. For more
you in a plan or program or to administer programs, and with other
		information, or access		to personal information in records
state and federal agencies as required by law.
			Purposes
		maintained by the Medi-Cal program and Covered California,
You must answer all of the questions on this renewal form unless		I can contact my county social ervices office or I can contact
		the Covered California		Privacy Officer at 1-800-300-1506
they are marked “optional.” If your renewal form is missing anything
		(TTY: 1-888-889-4500).
that we require, we will contact you to get it. If you do not provide it,

we will not be able to make a decision on your renewal. You may		I understand that to be eligible for Medi-Cal, I am required to
have to submit a new application, or you may not be able to get
		apply for other inc me		benefits to which I or any member of
health insurance through Covered California, or your application
		my household is entitled, unless he or she has good cause for
for benefits renewal may be denied.
		not doing so. exam les of such income or benefits are pensions,

In most cases, you have the right to see personal information		government benefits, retirement income, veteran’s benefits,
about you that is in federal and state records. You can see it in		ann ities, disability benefits, social security benefits (also
an alternative format (such as large print) if you need that. For		called OAsdI or Old Age, survivors, and disability Insurance),
more information or to see Covered California records, contact the		and unemployment benefits. But such income or benefits do
Privacy Officer at:		not include public assistance benefits, such as CalWOrKs or
	Informational
Covered California		Ca Fresh. If I have a question about a possible source of income,
		I can call my county social services office or Covered California at
Attn: Privacy Officer		1-800-300-1506 (TTY: 1-888-889-4500) for help.
P.O. Box 989725		I know that I must tell Covered California or my Medi-Cal county
West sacramento, CA 95798-9725
Phone: 1-800-300-1506		social services office about changes to anything I stated in this
TTY: 1-888-889-4500		renewal form. to report changes, I can call my county social
For the Department of Health Care Services,		services office. Or I can call Covered California at 1-800-300-1506
		(TTY: 1-888-889-4500) or visit CoveredCA.com.
contact the Information Protection unit t:		I know that Covered California or the Medi-Cal program must
P.O. Box 997413, Ms 4721
sacramento, Ca		not discriminate against me or anyone on this renewal form
95899-7413		because of race, color, national origin, religion, age, sex, sexual
Phone: 1-866-866-0602		orientation, marital status, veteran’s status, or disability. If I think
TTY: 1-877-735-2929		Covered California or the Medi-Cal program has discriminated
these state and federal laws give us the right to collect and keep		against me, including the failure to provide reasonable accom-
		modations as required under state and federal law, I can make a
the information	the re ewal form: Covered Ca: 42 u.s.C. §	complaint by contacting the u.s. Department of Health & Human
18031; CA Gove nment Code §§ 100502(k) and 100503(a) dHCs:		services at www.hhs.gov/ocr/office/file or the California
CA Welfa e and Institutions Code § 14011 and Article 3, Chapters		Office of the Attorney General at http://oag.ca.gov/contact/
5 and 7, Parts 2 and 3, division 9. We must give you this Privacy		general-comment-question-or-complaint-form.
statement under CA Civil Code § 1798.17.		If I believe that Covered California or the Medi-Cal program has
You can find the Notices of Privacy Practices for the Medi-Cal
		discriminated against me or anyone else on this renewal form in
program at www.dhcs.ca.gov and for Covered California at		connection with a Medi-Cal eligibility determination, I can also file
www.CoveredCA.com.		a complaint with the department of Health Care services, Office
		of Civil rights by calling 1-916-440-7370 (TTY: 1-916-440-7399).

I understand that any changes in my information or information						I know that I can find out how to appeal by calling 1-855-795-0634
of any member(s) in the applicant’s household may affect the						(TTY: 1-800-952-8349) for the Medi-Cal program or calling
eligibility of other members of the household.						1-800-300-1506 (TTY:1-888-889-4500) for Covered California
If applying for Medi-Cal, I confirm that no one applying for health						enrollees.
						I know that I must file an appeal within 90 days of the decision. I
insurance on this renewal form is confined, after the disposition of
charges (judgment), in a jail, prison, or similar penal institution or						know that I can represent myself or have someone else represent
correctional facility.						me in my appeal, such as an authorized representative, a friend,
I understand that I must report income changes to my Medi-Cal						a relative, or a lawyer.
						I know that if I need help, someone at Covered Ca ifornia, the
county social services office or Covered California because it may
affect the eligibility for Medi-Cal benefits or the amount of premium						Medi-Cal program, or the county social services office can explain
assistance (or tax credits) that I may be eligible to receive. I						my case to me.
also understand if I receive too much premium assistance (or						DECLARATION
tax credits) during the benefit year, I will have to repay the extra
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
taxes for the benefit year.						California that what I say below is true and correct.
I give my permission to the Medi-Cal program or Covered California						I understood all questions on this n		wal form and gave true and
to check other agencies’ computer records to verify citizenship,						correct answers as far as I know. Wh		re I did not know the answer
satisfactory immigration status, tax information, and other						myself, I made every rea onable att		mpt to confirm the answer
information related only to eligibility to see if I and other people on						with someone who did kn w.
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
renewal form qualifies for Medi-Cal:
I know that if Medi-Cal pays for a medical expense, any money I						be a civil or c iminal	enalty for perjury that may include up to four
						years in jail. (see California Penal Code section 126.)
or anyone on this renewal form get from other health insurance						I know that the information in this renewal form will be used to
or legal settlements related to that expense will go to Medi-Cal
as payment for the expense until the expense is paid in full. For						decide if the people who are applying qualify for health insurance.
parents whose child or children qualify for Medi-Cal:						the Medi-Cal program and Covered California will keep the
						information private, as required by federal and California law.
I know I will be asked to help the agency that collects medic						Purposes
						I agree to notify the Medi-Cal program or my Medi-Cal
support from any parent	this renewal			who does not live
with the child and does not send support				the child. If I thi k		county social services offices or Covered California by
that helping will harm me	my children, can tell the Medi-Cal					calling 1-800-300-1506 (TTY: 1-888-889-4500) or visiting
program and I will not have to help.						CoveredCa.com if anything changes on this renewal form
Your right to appeal: If		think	Covered	Cal forn a or the		for any person applying for health insurance.

Medi-Cal program has made		mistake, c		ppe	l i s decision.
to appeal means to tell someone			Covered C		lifornia or the
Medi-Cal program that think its decision is wrong and ask for
a fair review of the action.
signature of applicant or auth		rized representative
Date and Place:

It is time to renew your Medi-Cal coverage. We need some information from
			Purposes
you to help you keep your Medi-Cal for the next year.
	You Can Renew Your Medi-Cal in Any One of These Ways
	■ By Mail: Complete this form and		Office hours are [8:30 a.m. to
	mail it to:		5 .m. Monday to Friday].
	[Medicaid agency]	■ Online: renewing online is quick
	[100 state street]	■ Online: renewing online is quick
	[100 state street]		and easy. Go to
	[any city, state]		and easy. Go to
	[any city, state]
	Informational		www.coveredca.com
	■ In Person: Visit our office at		or [saWs online portal]
	[Medicaid agency]		to upload your documents.
	[100 state street]
	[any city, state]

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

	■ People in your household who	have Medi-Cal and who do not
	currently have Medi-Cal,	want to apply for Medi-Cal. Their
	■ People in your household who	informati n will be kept private and
	■ People in your household who	used only to help those in your
	would like to apply.	used only to help those in your
	would like to apply.	household who want to keep or
		household who want to keep or
	■ We may need some information	apply for Medi-Cal.
	about people in your household	You do not need to file a tax return

If anyone in your household does		kept private and will be used only to
not qualify for Medi-C l because		see if you or your family qualifies for
the information on this form has		affordable health coverage. We may
changed, we will use your new		need more information from you to
information to check to see if you		find you the most affordable health
or other people in your household		coverage. You do not need to file a
qualify	other affordable health	tax return to apply for or renew your
cove age, including Covered		Medi-Cal.
Calif rnia. Your information will be

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