Form Mc 223 - Applicant'S Supplemental Statement Of Facts For Medi-Cal Page 8
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8Continued answer(s) to question(s) number 8 on page 2, number 9 on page 3, and number 10 on
County Use Only
page 3. If you need more room, please ask your county worker for additional pages to complete.
List any additional clinic or hospital where you have been seen in the last 12 months.
❑
MC 220
Signed
Name of clinic/hospital
Clinic/hospital telephone number
Patient/clinic or member number
(
)
Name of doctor(s) seen
ADDRESS of clinic/hospital (number, street, suite)
City
State
ZIP Code
Date first seen
Date last seen
Date of next appointment
Reason for the visit(s)
Did you stay in the hospital overnight?
Yes
No
❑
❑
If YES, date(s) entered:
date(s) left:
Were you seen in the emergency room?
Yes
No
❑
❑
If YES, date(s) seen:
List ALL medicines received:
List ALL treatments received and the dates the treatments were received:
List any additional doctor you saw outside of the clinic(s) or hospital(s) you have already listed:
MC 220
❑
Name of doctor(s)
Signed
Patient/clinic or member number
Doctor’s telephone number
(
)
Name of doctor(s) seen
ADDRESS of doctor (number, street, suite)
City
State
ZIP Code
Date first seen
Date last seen
Date of next appointment
Reason for the visit(s)
List ALL medicines received:
List ALL treatments received and the dates the treatments were received:
List any additional tests you have had in the last 12 months:
MC 220
❑
NAME AND ADDRESS OF OFFICE, CLINIC, OR HOSPITAL
DATE
TEST PERFORMED
WHERE TEST(S) WAS COMPLETED.
(Month/Year)
Signed
Name
Address
(number, street, suite)
City
State
ZIP Code
MC 220
❑
Name
Signed
Address
(number, street, suite)
City
State
ZIP Code
Page 8 of 8
MC 223 (10/09)
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