Form Mc 360 - Notification Of Medi-Cal Intercounty Transfer
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1State of California—Health and Human Services Agency
Department of Health Care Services
NOTIFICATION OF MEDI-CAL INTERCOUNTY TRANSFER
Instructions: Complete each space or box. If information does not pertain to this case, indicate with N/A.
Receiving county name and address
Sending county name and address
Case Name/Beneficiary Information
Case name
Phone number
Alternate phone number
(
)
(
)
Address (number, street)
City
ZIP code
Authorized representative (AR)
AR name
AR phone number
Beneficiary’s primary language
(
)
Yes
No
Receiving county follow-up on changes related to intercounty transfer
Medi-Cal Family Budget Unit (If person is excluded, please indicate.)
Name
Aid Code
Income/How Often Received
Share-of-Cost (SOC)
Other Case Information
CE for: _________________________________________
Annual redetermination due date: ___________________
CEC for: ________________________________________
LTC period of ineligibility: __________________________
CEC period: _____________________________________
Court case: _____________________________________
TMC period: _____________________________________
Other: _________________________________________
Documents in Transfer Packet
Pregnancy verification for: _________________________
Statement of Facts and applicable supplements/MC 210 RV
Primary wage earner: _____________________________
Social security card(s)
MC 13s and Proof of Alien Status for: ________________
Identifications
_______________________________________________
Case narrative
Property verifications or MC 176 P
Budget work sheets for MFBU/MBU
Family Support Information (CW 2.1s)
Computer generated case documents
Authorized Representative Form/Letter
Last NOAs for share-of-cost
SP-DDSD Decision/Incapacity Verification for: _________
Income verifications
_______________________________________________
Other Health Coverage Information (DHCS 6155)
Other(s) (list): ___________________________________
Sending County Worker Information
Worker name
Worker number
Date ICT packet sent
Phone number
Fax number
E-mail address
(
)
(
)
MC 360 (06/07)
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