Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal
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8State of California—Health and Human Services Agency
Department of Health Care Services
County Use Only
APPLICANT’S SUPPLEMENTAL STATEMENT
OF FACTS FOR MEDI-CAL
County Number/Aid Code/Case Number
—
—
PART I—PERSONAL INFORMATION
1a. Applicant Name (Last, First, MI)
1b. Social Security Number
1c. Date of Birth
/
/
—
—
1d. Other Name(s) used (Last, First, MI)
1e. Sex
1f. Height
1g. Weight
❑
Male
Feet
Pounds
❑
Female
Inches
2a. Home address
City
State
ZIP Code
2b. Mailing address (if different)
City
State
ZIP Code
3.
Daytime telephone number
Check if:
Best time to call
❑
No Phone
Message Phone (
)
(
)
❑
4a. Do you speak English?
4b. Do you have
If YES, interpreter’s name:
Best time to call
an interpreter?
❑
❑
❑
Yes
No
Yes If YES, go to Part II
❑
No If NO, what language(s) do you speak:
Interpreter’s phone number:
(
)
PART II—MEDICAL INFORMATION
County Use Only
5.
Have you applied for Social Security Disability or Supplemental Security Income (SSI)
❑
❑
Disability benefits in the past two (2) years?
Yes
No
If YES, please answer the following:
a. Was/Is your Social Security or SSI Disability application:
❑
❑
❑
❑
❑
Approved?
Denied?
Pending?
On Appeal?
Unknown?
b. If approved or denied, give the date of the most recent decision on your Social Security or SSI
disability application:
❑
❑
c. Has your medical problem(s) worsened since the date in 5b above?
Yes
No
If YES, please explain:
d. Do you have any NEW medical problem(s) since the date in 5b, above, which you did NOT
have when your Social Security or SSI disability decision was made?
❑
Yes
❑
No
If YES, what medical problem(s)?
6.
List all medical problems (physical or mental) that keep you from working or taking care of your personal
needs. (Please attach additional sheet, if necessary.)
WHEN DID IT START
MEDICAL PROBLEM(S)
(Month/Year)
Page 1 of 8
MC 223 (10/09)
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