Form Dhcs 7020 - California Screening Work Sheet - Health And Human Services Agency
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1Department of Health Care Services
State of California—Health and Human Services Agency
SCREENING WORK SHEET
For aged, blind, or disabled persons who are potentially Pickle eligible
(Individuals in long-term care are not eligible under the Pickle program.)
Person’s name
Case name
Case number
Date SSI/SSP was last received __________________________ (must be verified in accordance with Title 22, California Code
of Regulations, Section 50167, unless person is on your 503 Leads list or the data is listed on the “INQE” screen of the Medi-Cal
Eligibility Data System [MEDS]).
NOTE: If SSI/SSP was never received or was received prior to April 1977, do not continue. The person is not eligible as a Pickle
person.
Screening Process:
YES NO
1. Does this person currently receive Title II benefits (RSDI*/Social Security)? ............................................................ ❒
❒
2. Since April 1977, has this person received or been entitled to receive both RSDI and SSI/SSP in
the same month?........................................................................................................................................................ ❒
❒
3. Has this person been discontinued from SSI/SSP?................................................................................................... ❒
❒
4. Has this person received an RSDI COLA increase in any month since SSI/SSP was discontinued? ...................... ❒
❒
The DHCS 7020 screening test is to be completed separately for each person who is a potential Pickle, even if he/she is part
of a couple. If the answers to all of the above questions are “yes,” the individual is a potential Pickle eligible. If only one in
dividual in a couple passes the screening test, then the potentially eligible individual must complete the DHCS 7021. If the
answer to any of the above questions is “no,” the person is currently ineligible as a Pickle person. In that situation, note the
reason for ineligibility and the verified date of last receipt of SSI/SSP on the DHCS 7020. The DHCS 7020 must be retained
permanently in the case file.
To determine if an individual or a couple that passed the screening test is actually eligible for the Pickle program, he/she or they
must pass the Pickle needs test. The individual or the couple must complete either the DHCS 7075 or the DHCS 7021, and
the Pickle Disregard Work Sheet (DHCS 7029). NOTE: If a couple is ineligible as a couple based on the DHCS 7075 or
DHCS 7021 , split the couple and complete a DHCS 7075 for each individual based on his/her income and the Pickle
disregard amount.
Reason for ineligibility: __________________________________________________________________________________
DHCS 7020 (06/07)
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