Form Mc 373 - County Referral To The Breast And Cervical Cancer Treatment Program
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1State of California – Health and Human Services Agency
Department of Health Care Services
COUNTY REFERRAL TO THE BREAST AND CERVICAL CANCER
TREATMENT PROGRAM
To:
From:
Department of Health Care Services
Name of County:
Breast and Cervical Cancer Treatment Program
Name of Eligibility Worker (EW):
MS 4611
P.O. Box 997417
Phone number of EW:
Sacramento CA 95899-7417
Fax number of EW:
Phone number: 916-322-3410
Fax number:916-440-5693
Applicant/Beneficiary Information:
Name:
Phone number:
Alternate/message phone
number:
Address:(number, street)
City:
Zip Code:
Authorized Representative:
AR Name:
AR Phone number:
Applicant’s/beneficiary’s
primary Language:
Yes
No
Case number:
CIN:
Case Information (check all that apply):
Referral is for an applicant.
Referral is for a beneficiary.
Case referred to the Disability Determination Service Division – State Programs for a
disability evaluation
Beneficiary put into an SB-87 Pending Disability aid code (6J, 6R, 5J or 5R).
Comments:
MC 373 (09/09)
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