Medi Cal Redetermination Form PDF Details

The Medi Cal Redetermination Form is a crucial form that is used to determine eligibility for the Medi-Cal program. This form must be completed by all applicants and renewal applicants, and any changes in income or household composition must be reported as soon. The information on this form will help determine whether an individual or family is eligible for Medi-Cal, and how much assistance they will receive. Make sure to complete this form accurately and thoroughly to ensure the best possible outcome for you or your family.

This figure features information about medi cal redetermination form. It might be beneficial to know its size, the actual time needed to complete the form, the fields you'll have to fill in, etc.

QuestionAnswer
Form NameMedi Cal Redetermination Form
Form Length4 pages
Fillable?Yes
Fillable fields111
Avg. time to fill out23 min 16 sec
Other namesmedical redetermination form, how to fill out medi cal annual redetermination form, medi cal redetermination, dpss lacounty gov annual redetermination en español

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State of California—Health and Human Services Agency

Department of Health Care Services

MEDI-CAL ANNUAL REDETERMINATION FORM

You must fill out this form and return it to the county to keep your Medi-Cal!

Case Number (optional)

Social Security Number (optional)

 

 

 

 

Print Your Full Name (if you have not moved, put address label here if one is provided)

Birth Date (optional) (mm/dd/yyyy)

 

 

 

 

Current Street Address, Apartment Number (check here if address is new)

City/State

Zip Code

 

 

 

Mailing Address (if different from above)

City/State

Zip Code

 

 

 

Use ink and Print your answers. Make sure you sign and date the form. Use the postage paid envelope to return it. If you need more space, attach a separate sheet to this form. If you have any questions or need help filling out this form, call your worker at the telephone number listed on the Annual Redetermination Notice.

Section 1. Income

(a)Do you or any family member in the home get money from a job, child support or alimony, social security, veteran benefits, unemployment or disability benefits, retirement, gifts, or interest or

dividends?

Yes No

If yes, complete below and list each source of income on a separate line.

Attach most recent pay stubs showing income before taxes or deductions, benefit or award letters, checks received or signed statement from employer, or last year’s federal income tax return. If income is from self-employment, send a copy of your most recent tax return or profit and loss statement.

Name of Person with Income

(include first and last name)

Source of Income

Income Amount

(before any deductions)

How Often Paid (weekly, monthly, twice a month)

Hours Worked

(per week or

month)

(b) Do you or any family member in the home get rent, utilities, food, or clothing entirely free?

Yes No

If yes, who?

 

 

What was free?⁜

 

 

(c) Was the free rent, utilities, food, or clothing received in exchange for work done?

Yes No

MC 210 RV (5/11)

Page 1 of 4

State of California—Health and Human Services AgencyDepartment of Health Care Services

Section 2. Expenses and Deductions

 

Do you or any family member in the home pay for child or adult care, health insurance or Medicare

 

premiums, court-ordered child support or alimony, or educational expenses?

Yes No

If yes, complete below and list each expense/deduction on a separate line.

 

Attach proof of expenses/deductions.

 

Name of Person

with Expense/Deduction

(include first and last name)

Type of

Expense or Deduction

Amount of

Payment

Paid to Whom

How Often Paid (weekly, monthly, twice a month)

Section 3. Other Health Insurance

 

(a) Did you or any family member have a change in, or get new health, dental, vision, or Medicare

 

coverage or insurance within the last 12 months?

Yes No

If yes, who has the coverage/insurance?

 

 

Which type of coverage/insurance?

 

 

 

(b) Is any family member living in the home receiving kidney dialysis-related services?

Yes No

If yes, who?⁜

 

 

(c) Has any family member living in the home received an organ transplant within the last 2 years?

Yes No

If yes, who?⁜

 

 

Section 4. Living Situation

(a)Did anyone move into or out of your home, move in with someone else, get married, or have a baby within the last 12 months? (Examples: newborn, child, or adult moved in or out of the home, absent

parent returns home.)

Yes No

If yes, complete below:

Name (include first and last name)

Relationship to You

What Changed?

Date Changed

(b) Does anyone in the home want Medi-Cal who is not already receiving it?

 

 

 

 

 

Yes No

If yes, who?⁜ ؠ

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(c) If a new baby is in home, where was the baby’s place of birth?

⁜ |

|

 

 

 

 

City

 

 

State

 

Country

 

MC 210 RV (5/11)

Page 2 of 4

State of California—Health and Human Services AgencyDepartment of Health Care Services

Section 4. Living Situation continued

 

 

 

(d) Did anyone in the home get inpatient care in a nursing facility or medical institution?⁜

Yes No

If yes, who?⁜

 

 

 

 

 

 

 

 

Yes No

(e) Is anyone in the home pregnant?

 

 

If yes, who?

 

 

 

 

Number of babies expected

 

Due date: ⁜

 

 

Section 5. Real or Personal Property

(a)Indicate the total amount of cash and uncashed checks held by any family member in the home $

(b)Does anyone have a checking or savings account, life insurance, long-term care insurance, motor vehicle, court-ordered settlement or judgement, stocks, bonds, retirement funds, trusts where money or property is held for the benefit of any family member in the home, real estate, motor vehicles for a business, business accounts or property, promissory notes, mortgages, deeds of trust, recreational vehicles, burial trusts or funds, annuities, jewelry (not heirloom or

wedding), or oil or mineral rights?

Yes No

(c)Did you or any family member in the home sell or give away any money or property in the past 12 months, or have any of the items listed in this section been spent or used as security

for medical costs?

Yes No

Note: If you have answered “yes” to questions (b) or (c), you will also have to fill out a property

 

supplement form, submit the form to the county and provide verification.

 

Section 6. Immigration or Citizenship Status Change

 

Has there been a change in immigration or citizenship status for anyone in the home that has Medi-Cal

 

or wants Medi-Cal within the last 12 months? (If your immigration status has changed, you might qualify for

 

full scope Medi-Cal benefits.)

Yes No

If yes, list the name(s) below and send proof of new status.

 

Name of Person

(include first and last name)

Status Change

(send proof of status)

Section 7. Blindness/Disability/Incapacity

 

 

 

(a)

Do you or any family member in the home have a physical or emotional condition that makes it

 

 

 

 

difficult to work, take care of personal needs, or take care of your children?  ⁜

 

 

Yes No

 

If yes, who?

 

 

 

 

(b) Was the physical, mental, or health condition a result of an injury or accident?

 

 

Yes No

 

If yes, explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MC 210 RV (5/11)

Page 3 of 4

State of California—Health and Human Services Agency

Department of Health Care Services

Section 8. Other Health Program Information and Referrals

(a)

Check this box if you do not want your child’s information shared with the low-cost Healthy

 

 

 

Families Program if your child gets Medi-Cal with a share of cost.

 

 

(b) Do you want information on the no-cost health program for children under 21 (Child Health

 

Yes No

 

and Disability Prevention Program, also known as CHDP?)

 

(c) Do you want information on the no-cost supplemental food program for pregnant or breast

 

 

 

feeding women and children under 5 (Women, Infants, and Children Program, also known

 

 

 

as WIC)?

 

Yes No

(d) Do you want information on the Personal Care Services Program, an in-home care program

 

 

 

for aged, blind, or disabled persons (also known as In-Home Supportive Services)?

Yes No

Section 9. Signature and Certification

Person completing this form must read and sign below.

I have received and read a copy of the Important Information for Persons Requesting Medi-Cal form (MC 219).

I am aware of, understand, and agree to meet all my responsibilities as described on the MC 219 form.

I certify that I will report all income, property, and/or other changes that may affect Medi-Cal eligibility within ten days of the change.

I understand that all of the statements, including benefit and income information, that I have made on this form, may be subject to investigation and verification.

I declare, under penalty of perjury, under the laws of the State of California that all information provided on this ⁜ form is true and correct.

Signature

Date

Daytime or Message Telephone Number

Home Telephone Number (check here if new number)

 

 

Signature of Witness (if signed by a mark), Interpreter or Person Assisting

 

 

 

County Use Only

Referrals

 

Follow-up Forms

 

 

HF

WIC

MC 13

MC 210 PS

Other:

CHDP

PCSP

 

DDSD Packet

 

MC 210 RV (5/11)

Page 4 of 4

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The PDF document you desire to prepare will include the next areas:

dpss lacounty gov annual redetermination en español fields to complete

Provide the requested data in the Yes, No Name, of, Person, with, income include, first, and, lastname Source, of, income income, Amount before, any, deductions Hours, Worked, per, week, or month, Yes, No and If, yes, who field.

Finishing dpss lacounty gov annual redetermination en español step 2

The application will request information to conveniently prepare the section If, yes, who What, was, free Yes, No and MCR, V, Page, of

stage 3 to entering details in dpss lacounty gov annual redetermination en español

When it comes to paragraph Yes, No Attach, proof, of, expenses, deductions Name, of, Person type, of Expense, or, Deduction Amount, of, Payment Paid, to, Whom Section, Other, Health, insurance Yes, No If, yes, who, has, the, coverage, insurance Which, type, of, coverage, insurance Yes, No If, yes, who and Yes, No state the rights and responsibilities.

Filling in dpss lacounty gov annual redetermination en español stage 4

Look at the sections Yes, No If, yes, who Section, Living, Situation parent, returns, home Yes, No If, yes, complete, below Name, include, first, and, lastname Relationship, to, You What, Changed Date, Changed Yes, No and If, yes, who and thereafter complete them.

step 5 to filling out dpss lacounty gov annual redetermination en español

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Step 4: In avoiding potential future difficulties, make sure to obtain more than two copies of each separate form.

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