Form Mc 4033 - Disability Listing Update
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1Department of Health Care Services
State of California—Health and Human Services Agency
DISABILITY LISTING UPDATE
Please indicate which list is to be updated with a check mark.
Medi-Cal liaison(s) for disability issues.
Medi-Cal liaison(s) for quarterly status listings for pending and closed disability cases.
Please use this form to transmit the name of your county’s representative, or in counties where multiple contacts will be
necessary, please provide the same information for each representative on a separate form. It would be appreciated if the
information is printed or typed.
County
Liaison
Liaison’s position title
Liaison’s telephone number
Alternative telephone number
(
)
(
)
Office address (number, street)
City
State
Zip code
RETURN TO: Department of Health Care Services
Medi-Cal Eligibility Division
Attn: Disability Liaison Coordinator
1501 Capitol Avenue, MS 4607
P.O. Box 997417
Sacramento, CA 95899-7417
MC 4033 (06/07)
Department of Health Care Services
State of California—Health and Human Services Agency
DISABILITY LISTING UPDATE
Please indicate which list is to be updated with a check mark.
Medi-Cal liaison(s) for disability issues.
Medi-Cal liaison(s) for quarterly status listings for pending and closed disability cases.
Please use this form to transmit the name of your county’s representative, or in counties where multiple contacts will be
necessary, please provide the same information for each representative on a separate form. It would be appreciated if the
information is printed or typed.
County
Liaison
Liaison’s position title
Liaison’s telephone number
Alternative telephone number
(
)
(
)
Office address (number, street)
City
State
Zip code
RETURN TO: Department of Health Care Services
Medi-Cal Eligibility Division
Attn: Disability Liaison Coordinator
1501 Capitol Avenue, MS 4607
P.O. Box 997417
Sacramento, CA 95899-7417
MC 4033 (06/07)
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