Form Mc 176 Pa-A - Medi-Cal Property Assessment Application printable pdf download

Form Mc 176 Pa-A - Medi-Cal Property Assessment Application

Department of Health Care Services

State of California—Health and Human Services Agency

MEDI-CAL PROPERTY ASSESSMENT APPLICATION

For either the institutionalized spouse if institutionalized on or

after September 30, 1989, or his/her spouse

This assessment will provide you with information on what property is counted for Medi-Cal purposes and how that property

would be valued if you or your spouse were applying for Medi-Cal benefits as an institutionalized spouse.

You are eligible for this assessment, only if you or your spouse:

One spouse is institutionalized on or after September 30, 1989, and

The other spouse does not reside in a nursing facility or medical institution receiving a nursing facility level of care, and

You have verification with you at the time of your appointment of the values of all your real and personal property, liquid

and nonliquid assets.

IMPORTANT: The property the community spouse is allowed to retain when the institutionalized spouse applies for Medi-Cal

is computed at the time of application for benefits. If you are not applying for Medi-Cal at the same time that this assessment is

being done, please be aware that the amounts shown on the property assessment may change when you do apply for

Medi-Cal. This can be caused by the appreciation in the value of real estate, changes in the values of stocks and bonds,

accumulation of interest and dividends, the sale of property considered exempt for Medi-Cal purposes, the acquisition of new

property, etc. In addition, please be aware that the values that you provide may also change when the county conducts

third-party verification of the information you provide at the time of application for benefits.

I understand that this assessment will be completed on the basis of current regulations and information which I provide. I also

understand that unless this assessment is being done at the same time as my or my spouse's application for Medi-Cal, the

amounts shown may be different when an application for benefits is eventually made.

Institutionalized individual's signature

Date

Community spouse's signature

Date

Signature of representative of either spouse

Date

NOTE: This form must be signed by at least one of the above.

I have read and reviewed the Property Assessment Application and Statement of Facts with the assessment applicant(s).

Eligibility Worker’s signature

Date

White—County

Yellow—Institutionalized Spouse

Pink—Community Spouse

Green—Spouse's Representative

MC 176 PA-A (05/07)

Form Mc 176 Pa-A - Medi-Cal Property Assessment Application