Form Mc 363 - Medi-Cal To Healthy Families Transmittal

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State of California—Health and Human Services Agency

Department of Health Care Services

MEDI-CAL TO HEALTHY FAMILIES TRANSMITTAL

County name

Healthy Families

County representative

P.O. Box 138005

Telephone number

Sacramento, CA 95813-9984

Date referred

Case name

(last)

(first)

Case number

Applicant name

(last)

(first)

Language

Applicant phone number

Spoken: _________________________

Written:

One or more individuals (check all applicable boxes):

Type of application (check all applicable boxes):

Changed mind about not wanting Healthy Families

Food stamps only application

❒ Were determined ineligible for Medi-Cal (see comments)

❒ School lunch application

Were determined to have a share-of-cost (see below)

Redetermination (RV)

Individual

Type of

LIST ALL HOUSEHOLD MEMBERS

Requested

M/C FBU

CIN

Social Security

Sex

Relationship to

Gross

Income

Share-of-Cost

Yes

Last Name

First Name

Number

Male Female

Date of Birth

Applicant

Income

(UIB, SDI)

Amount

ENCLOSURES: the following documents are enclosed with the application (check all applicable boxes).

Mandatory:

Medi-Cal NOA(s) and Medi-Cal Budgets (if not on NOA)

If available:

Birth certificate

Immigration

Residency

Copy of appropriate application

Other

______________________________________________

Comments: Explain why county is forwarding the application. If a member of the household is on CalWORKS, SSI, or Foster Care, please indicate person(s) and type(s)

of assistance.

MC 363 (05/07)