Form Dhcs 7071 - California Medical Waiver Information And Authorization - Health And Human Services Agency

ADVERTISEMENT

Department of Health Care Services
State of California—Health and Human Services Agency
COUNTY USE ONLY
MEDI-CAL WAIVER INFORMATION
Case name
Case number
AND
AUTHORIZATION
Worker name
Worker number
Parent/Guardian: If your child was receiving Supplemental Security Income (SSI) payments while in an institution, is under 18 years of age, is now
receiving Medi-Cal benefits, is now living at home, and is currently in a home- and community-based waiver program, he/she may be eligible to
receive a monthly SSI personal needs payment. Please complete this portion of the form and forward to the County Waiver Person if your child is in
a Medi-Cal In-Home Operations or Developmental Services Waiver. For other waivers, forward this form to the State of California, Department of
Health Care Services, Medi-Cal Eligibility Division, Mail Station 4608, P.O. Box 997413, Sacramento, CA 95899-7413. After the County or State has
verified that your child is in a Medi-Cal waiver, submit this form to the Social Security Administration for a determination. SSA will continue to
contact the County or State each year prior to continuing the personal needs payment.
Name of child
Address (number, street)
City
State
ZIP code
Social Security number
Date of birth
Telephone
(
)
Parent/Guardian
Address of parent/guardian (if different)
City
State
ZIP code
Type of waiver
I, the parent or guardian of the above child, authorize the County of _____________________________ or the State of California to disclose
to the Social Security Administration information about the above child’s status in the MediCal home- and community-based waiver program.
Signature
Date
COUNTY DEPARTMENT OF SOCIAL SERVICES: Please verify that the above child is currently receiving Medi-Cal benefits at home
and is receiving services under the Model or DDS waiver.
I certify that the above named child is receiving Medi-Cal benefits under one of the following home- and community-based waivers:
Medi-Cal In-Home Operations Waivers Nursing Facilities Waiver (Parental income and resources do not apply.)
Developmental Services Waiver (Parental Income and resources do not apply.)
Signature of county authorizing person
Printed name
Title
Telephone
(
)
County address (number, street)
City
State
ZIP code
STATE OF CALIFORNIA, DEPARTMENT OF HEALTH CARE SERVICES: Please verify that the above child is currently receiving
Medi-Cal benefits and receiving waiver services.
Signature of state authorizing person
Printed name
Title
Telephone
(
)
State address (number, street)
City
State
ZIP code
White: Parent copy
Yellow: County copy
DHCS 7071 (06/07)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go