Form Cf 31 - Calfresh Supplemental Form For Special Medical Deductions Page 2
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1
2State of California – Health and Human Services Agency
California Department of Social Services
Name of elderly
What type
Amount
How often
Will the household be
or disabled
of expense?
of
paid?
reimbursed for any medical
person
expense?
expenses? (By Medi-Cal,
(prescriptions,
(monthly,
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 $
The supplemental form for special medical deductions is for any CalFresh household member who is
elderly or disabled.
When we say “elderly” we mean anyone who is age 60 or older.
When we say “disabled” we mean anyone who is getting:
1) Disability payments from the Social Security Administration (SSA) (other than Supplementary
Security Income/State Supplementary Program (SSI/SSP)) or the Veterans Administration
(VA); OR
2) Disability retirement benefits from a federal, state or local governmental agency or the Railroad
Retirement Board; OR
3) Medi-Cal services because of a disability; OR
4) Interim assistance/emergency general relief while waiting to get SSI/SSP because of a
disability approved by the Social Security Administration.
Examples of Verifications:
•
Medical bills or receipts
•
Medical transportation bills or receipts
•
Health or dental insurance policies or premiums
•
Medicare card (for Medi-Cal only)
•
Doctor statement or disability finding by an agency (SSA/VA, etc.)
•
Medical verification form (CW61)
CF 31 (1/18) Recommended Form
Page 2 of 2
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