Form Mc 274 Tb - Medi-Cal Tuberculosis Program Application Page 2
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1
2
3Department of Health Care Services
State of California—Health and Human Services Agency
MEDI-CAL TUBERCULOSIS PROGRAM
COUNTY USE ONLY
EW name: ______________________
REFERRAL
EW number: ____________________
Case number: ___________________
Case name:_____________________
This form must be completed in order to determine the person’s eligibility
for the Medi-Cal Tuberculosis Program.
Please print clearly.
PATIENT NAME
DATE OF BIRTH—Month/Day/Year
SOCIAL SECURITY NUMBER
—
—
PATIENT CONSENT
I consent to this information being forwarded to the county welfare office.
SIGNATURE OF PATIENT OR PARENT/GUARDIAN (if patient is under 18 years of age)
➤
PROVIDER USE ONLY
If either question is answered “Yes,” the patient, ________________________________, is Tuberculosis infected.
1. Requires preventive therapy for Tuberculosis infection.
Yes
No
2. Requires treatment for active Tuberculosis.
Yes
No
RETROACTIVE ELIGIBILITY
This person has been under therapy for Tuberculosis within the past three months prior to application.
Yes—Date Tuberculosis therapy began: ____________________________________
No
Provider or clinic staff: Please complete the MC 210 A if answer to the above question is “Yes” and patient believes
he/she is eligible for retroactive benefits.
If this person is Tuberculosis infected, please mail Parts A, B, and C of the MC 274 TB form to the local
county welfare office for a Medi-Cal determination under the Tuberculosis program.
PHYSICIAN NAME (Please stamp, print, or type.)
TELEPHONE NUMBER
(
)
PHYSICIAN TITLE
MEDI-CAL PROVIDER NUMBER
DATE
PROVIDER ADDRESS (Number/Street)
City
ZIP Code
AUTHORIZED PROVIDER SIGNATURE
➤
ORIGINAL—County Welfare Department
COPY—Provider
COPY—Patient
MC 274 TB (05/07) Part B—Referral
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