Form Mc 364 - California Department Of Aging (Cda) Waiver Referral
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1Department of Health Care Services
State of California—Health and Human Services Agency
Medi-Cal Program
CALIFORNIA DEPARTMENT OF AGING (CDA)
COUNTY USE ONLY
Case name
Case number
WAIVER REFERRAL
Worker name
Worker number
Multipurpose Senior Services Program (MSSP) site: Please complete this portion and forward to the
appropriate County Waiver contact person.
Name of applicant
Address (number, street)
City
State
ZIP code
Social security number
Date of birth
Telephone
(
)
Guardian (if applicable)
Address of guardian (if different)
(number
, street)
City
State
ZIP code
Status
New Medi-Cal applicant.
Currently receives Medi-Cal with a share-of-cost.
Living Arrangement
The applicant is currently in an institution. Please determine Medi-Cal eligibility based on his/her
anticipated return to the community. Anticipated date of discharge:
The applicant is currently living in the home.
Other:
Eligibility Determination
If applicant/beneficiary is living or will live at home with his/her spouse and is property eligible and
entitled to zero share-of-cost Medi-Cal under regular eligibility rules, spousal impoverishment rules
are not utilized. If the applicant/beneficiary is property ineligible or has a share-of-cost, apply spousal
impoverishment income and resource rules (i.e., institutional deeming rules) even if the
applicant/beneficiary lives in the home. See Article 19D of the Medi-Cal Eligibility Procedures
Manual.
This is to certify that the individual named above has met the admission criteria for a nursing facility
as defined in the California Code of Regulations, Title 2, Division 3, Subdivision 1, Chapter 3,
Article 4, Sections 51334 and 51335.
Signature of MSSP site contact person
➤
Printed name of MSSP site contact person
Title
Telephone
(
)
MSSP site address (number, street)
City
State
ZIP code
NOTE TO COUNTY: Please send a copy of the Notice of Action to the MSSP site when the determination is completed.
White: County Copy
Yellow: MSSP Site Copy
MC 364 (05/07)
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