Form Mc 176 Tmc - Transitional Medi-Cal (Tmc) Quarterly Status Report
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1
2State of California—Health and Human Services Agency
Department of Health Care Services
TRANSITIONAL MEDI-CAL (TMC)
QUARTERLY STATUS REPORT
This status report is for the months of
Return this form no later than
Month 1
Month 2
Month 3
the 21st day of
IMPORTANT: COMPLETE, SIGN, AND RETURN THIS REPORT TO THE WELFARE DEPARTMENT IN THE ENCLOSED ENVELOPE.
Attach proof of your income, actual child care expenses paid, and total hours of employment for the three months noted above. If you have
any questions regarding this form or the items to be reported, contact your eligibility worker.
For Transitional Medi-Cal (TMC)—You will receive status reports during this period. If you do not complete and return these reports,
your eligibility for TMC will be discontinued.
PART A. DISCONTINUANCE REQUEST
I request that my Transitional Medi-Cal be stopped on the last day of
_____________________
Month/Year
I know that I can reapply for Medi-Cal at any time.
______________________________________________
____________________
Applicant signature
Date
IF YOU WANT YOUR TMC ELIGIBILITY TO CONTINUE, PLEASE COMPLETE AND SIGN PART B OF THIS REPORT.
PART B. ELIGIBILITY STATUS INFORMATION
1.
Did anyone receive any income, money, or benefits during the report period such as salary, wages, tips,
❒ Yes
❒ No
commissions, bonuses, vacation pay? If yes, attach proof (all pay stubs) for each report month.
Name
Month 1
Month 2
Month 3
❒ Yes
❒ Yes
❒ Yes
Income received?
❒ No
❒ No
❒ No
Employer/source
Total hours worked:
__________
__________
__________
Name
Month 1
Month 2
Month 3
❒ Yes
❒ Yes
❒ Yes
Income received?
❒ No
❒ No
❒ No
Employer/source
Total hours worked:
__________
__________
__________
Name
Month 1
Month 2
Month 3
❒ Yes
❒ Yes
❒ Yes
Income received?
❒ No
❒ No
❒ No
Employer/source
Total hours worked:
__________
__________
__________
Name
Month 1
Month 2
Month 3
❒ Yes
❒ Yes
❒ Yes
Income received?
❒ No
❒ No
❒ No
Employer/source
Total hours worked:
__________
__________
__________
2.
Did you or any family member receive money or benefits from other sources such as disability, unemployment,
❒ Yes
❒ No
child support, or social security? If yes, attach proof (all pay stubs) for each report month.
Name
Month 1
Month 2
Month 3
❒ Yes
❒ Yes
❒ Yes
Income received?
❒ No
❒ No
❒ No
Employer/source
Name
Month 1
Month 2
Month 3
❒ Yes
❒ Yes
❒ Yes
Income received?
❒ No
❒ No
❒ No
Employer/source
Name
Month 1
Month 2
Month 3
❒ Yes
❒ Yes
❒ Yes
Income received?
❒ No
❒ No
❒ No
Employer/source
MC 176 TMC (05/07)
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