State of California – Health and Human Services Agency
California Department of Social Services
CALFRESH SUPPLEMENTAL FORM
FOR SPECIAL MEDICAL DEDUCTIONS
Case Name: ______________________________________ Case Number: ____________________
This form is for special medical deductions for any CalFresh household member who is elderly or
disabled. See the other side of this page for what we mean when we say “elderly or disabled.”
Are you, or anyone you buy and prepare food with, an elderly (60 or older) or disabled person that
has any out-of-pocket medical expenses?
Yes
No
n
If yes, please check all the boxes of the types of medical expenses that apply from these examples
listed below (there may be others not listed here). List expenses you expect to have during the
certification period. Please complete the section below and attach bills, receipts, or proof of
expenses.
NOTE: Don’t list spouses or children receiving dependent payments from Social Security
Administration (SSA) Veteran’s Administration (VA), etc. Allowable medical expenses are:
The number and cost of meals furnished to an
Medical or dental care
attendant
Prescribed over the counter medications
Prescribed medication
Dentures, hearing aids and prosthetics
Medicare premiums (Medi-Cal share of costs,
Prescribed eye glasses contact lenses
etc.)
Maintaining an attendant necessary due to
Service animals (i.e. seeing eye or hearing
age, illness, or infirmity
dog) expenses (food and vet bills, etc.)
Hospitalization or outpatient treatment/nursing
Cost of lodging to obtain medical and to obtain
care
medical treatment or services
Health and hospitalization insurance policy
premiums
Other (specify): ________________________
Prescribed medical supplies and equipment
_____________________________________
Cost of transportation (mileage or fee)
treatment or services
Name of elderly
What type
Amount
How often
Will the household be
or disabled
of expense?
of
paid?
reimbursed for any medical
person
(prescriptions,
expense?
(monthly,
expenses? (By Medi-Cal,
dentures, # of meals
weekly,
insurance, etc.)
for attendant, etc.)
other)
If yes, by who:
How much $
If yes, by who:
How much $
If yes, by who:
How much $
CF 31 (1/18) Recommended Form
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