Form Mc 179 - Information Letter

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State of California – Health and Human Services Agency
Department of Health Care Services
(County Stamp)
Notice date: _________________________
Case number: ________________________
Worker name: ________________________
Worker number: ______________________
Worker telephone number: ______________
Office hours: _________________________
Notice for: ___________________________
_____
This letter is to tell you that all of the information necessary to refer your case to State
Programs, Disability Determination Service Division for a disability determination has not
been received.
Though federal law requires that eligibility for Medi-Cal based on disability be decided within
90 days, we are not able to do so in your case due to the reason(s) checked below.
We are awaiting the following information:
For you to respond to our request for additional information
(__________________________________________________________)
For you to respond to our request to come into the office
For you to contact your eligibility worker RIGHT AWAY because your disability
form(s) is not completed correctly
Other:
If you have questions about your Medi-Cal application, call me at (
)
________________________ between ______________ a.m. and __________________
p.m.
MC 179 (11/07)

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