Form Mc 262 - Redetermination For Medi-Cal Beneficiaries (Long-Term Care In Own Mfbu) Page 3

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17. Do you have Medicare coverage?............................................................................................................

Yes

If yes:

Name

Medicare claim number

Monthly premium

Deduction from check?

Yes

Date verified

Paid by you?

Yes

18. Do you have health or hospitalization insurance?....................................................................................

Yes

DHCS 6155 completed?

If yes:

Yes

Name of insurance company

OHC Code ________________

Premium you pay

How often?

Monthly

Quarterly

Yearly

Service Referral

Yes

19. Would you like to speak to a social worker about services available to you? ..........................................

Yes

If yes, explain the services you wish to discuss:

20. Additional information

BE SURE YOU HAVE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONS.

READ THE FOLLOWING CAREFULLY BEFORE SIGNING.

I declare under penalty of perjury that the answers I have given are correct and true to the best of my knowledge.

I agree to tell the county welfare department within ten days if there are any changes in my (or the person’s on whose behalf I am acting) income, possessions,

or expenses, or a change in my living situation. I agree to meet all the other responsibilities explained in the “Important Information for Persons Requesting

Medi-Cal” (MC 219) I received at the time of my application for Medi-Cal. (A new “Important Information for Persons Requesting Medi-Cal” (MC 219) will be

provided if there is a change in the person acting on behalf of the beneficiary.)

I understand that Section 1137 of the Social Security Act requires that I provide my Social Security number (SSN). My SSN will be verified and will be used in

a computer match to check the income and resources I report with information from welfare, state employment, income tax, Social Security Administration, and

other agencies.

I understand that Sections 215, 9202, and 9203 of the Probate Code and Section 14009.5 of the Welfare and Institutions Code provide for the recovery of all

Medi-Cal benefits received after age 55 from the estate of a Medi-Cal beneficiary if there is no surviving spouse, minor children, or blind or totally disabled

children, or it would create a hardship for my heirs. After the death of my surviving spouse, the State has the right to claim from the part of his/her estate

received from me, all Medi-Cal benefits I received after age 55 up to the amount of property my spouse received from my estate.

I understand that I may be asked to prove my statements, but that the county is required by law to keep them confidential.

I understand that if I am dissatisfied with any action or inaction taken by the county welfare department, I have the right to a state hearing which I may request

from the county welfare department within 90 days after the action or inaction with which I am dissatisfied.

I realize that if I deliberately make false statements or withhold information, I (or the person on whose behalf I am acting) may lose my (or his/her) Medi-Cal

card and/or be prosecuted for fraud.

Signature of beneficiary

Date

Signature of person acting for beneficiary

Date

Signature of witness (if beneficiary signed with mark)

Date

E.W. signature

Date

MC 262 (06/07)

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