Form Mc 262 - Redetermination For Medi-Cal Beneficiaries (Long-Term Care In Own Mfbu)

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Department of Health Care Services
State of California—Health and Human Services Agency
REDETERMINATION FOR MEDI-CAL BENEFICIARIES
(LONG-TERM CARE IN OWN MFBU)
INSTRUCTIONS: Your continuing eligibility will be decided on the information you give on this form. If you are completing this
form on someone else’s behalf, the term “you” applies to that person. ALL QUESTIONS MUST BE ANSWERED.
1.
Name (first, middle, last)
Date of birth (month, day, year)
Social security number
2.
Long-term care facility name
Marital status
Medicare claim number
Facility address (number, street)
City
ZIP code
3.
Name of spouse
Social security number
Telephone
(
)
Address of spouse (number, street)
City
State
ZIP code
4.
Name of person helping complete form
Relationship
Telephone
(
)
5. Address of person helping with form (if information regarding beneficiary should be sent to this person)
Number, street
City
State
ZIP code
COUNTY USE ONLY
6. Do you own any real property, have an interest in real property, or own a trailer or mobile home taxed
as real property? ......................................................................................................................................
Yes
No
PR
Yes
No
If yes:
a. Is this property your former home? .....................................................................................................
Yes
No
If yes, do you intend to return to that property to live in the future?....................................................
Yes
No
(If this intent changes, you must notify the county within 10 days.)
If you do not intend to return to that property, does anyone else live there now? ..............................
Yes
No
If yes, enter name:___________________________________Relation to you: ____________________________
Basis of dependency (financial, medical, etc.) ______________________________________________________
How
long have they lived there?
________________________________________________________________
b. Is this property currently listed for sale? .............................................................................................
Yes
No
DHCS 7014
Description of property: ________________________________________________________________________
Address of property: __________________________________________________________________________
Owner(s):___________________________________________________________________________________
Full value (from tax statement):
$ ___________________
Amount owed:
$ ___________________
Rent collected each month:
$ ___________________
Expenses on property:
$ ___________________
Utilized
Yes
No
Interest
$ ____________
Insurance $ ___________
Yearly
Monthly
Yearly
Monthly
Taxes and assessments
$ ____________
Yearly
Monthly
Upkeep and
Utilities
$ ____________
repairs
$
___________
Yearly
Monthly
Yearly
Monthly
7. Do you have a life estate in any property? ...............................................................................................
Yes
No
If yes, describe:_________________________________________________________________________________
$_________________
8. Do you own a note, mortgage, or deed of trust? ......................................................................................
Yes
No
If yes:
Appraised value
$
_____________
Monthly payment: $ ______________
Interest rate: ___________%
9. Do you have any checks or money on hand in banks, savings and loans, or credit unions, etc.
Current month income
included
(checking or savings accounts), or a patient trust account, or a trust or agreement where money or
Yes
No
property is being held for your benefit or being held for you by anyone, or being kept anywhere
for you? ....................................................................................................................................................
Yes
No
If yes:
a.
On hand?
_________________________________________________________
$_________________
Location
Amount
Account number
$_________________
b.
In bank or savings?
_________________________________________________________
Location
Amount
Account number
$_________________
_________________________________________________________
Location
Amount
Account number
$_________________
c.
Held or kept for you by anyone?
_________________________________________________________
Location
Amount
Account number
MC 262 (06/07)
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