Form Mc 174 - Medi-Cal Notice To Providers Clarification Of Liability
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1State of California—Health and Human Services Agency
D epartment of Health Care Services
MEDI-CAL NOTICE TO PROVIDERS
CLARIFICATION OF LIABILITY
NOTE: If you are not a Medi-Cal provider
please disregard this notice.
________________________________________________________________
(Provider’s Name)
________________________________________________________________
(Address)
_
_ ______________________________________________________________________________
(City, State, ZIP code)
Dear _____________________________________________
(Provider’s Name)
This is to provide you with notification that the Medi-Cal Program is not liable for services provided:
La presente es para notificarle que el programa de Medi-Cal no es responsable de los servicios proporcionados:
To:
_________________________________________________________
(Name of Beneficiary) (Nombre del Beneficiario)
A:
On:
_______________________________________, totaling $ ______________________
(Date) (Fecha)
con un total de
En:
_______________________________________, totaling $ ______________________
(Date) (Fecha)
con un total de
_______________________________________, totaling $ ______________________
(Date) (Fecha)
con un total de
The expenses indicated above were used by the
Los gastos que se indican arriba fueron usados por el
beneficiary to reduce the value of excess property to
beneficiario para reducir el valor de bienes en exceso,
establish or maintain Medi-Cal eligibility for the month of
para establecer o continuar reuniendo los requisitos
____________________,
20
____.
Under Section
para Medi-Cal para el mes de _________________,
14019.3(d), Welfare and Institutions Code, the
20____. En conformidad con la sección 14019.3(d) del
beneficiary is not entitled to a refund or release of his/her
Código de Bienestar e Instituciones, el beneficiario no
liability for these expenses. (Medi-Cal is not liable for
tiene derecho a reembolso o liberación de su
these medical expenses.) None of these expenses used
responsabilidad con relación a estos gastos. (Medi-Cal
by the beneficiary to reduce the value of his/her excess
no es responsable de estos gastos médicos.) Ninguno
property, may be used to meet his/her share of cost.
de estos gastos que usó el beneficiario para reducir el
valor de sus bienes en exceso, puede ser usado para
cumplir con su parte del costo.
__________________________________________________________
_____________________________________________________
_________________________________________
(Eligibility Worker) (Trabajador(a) de Elegibilidad)
(Phone Number) (Número de Telêfono)
(Date) (Fecha)
Permission to release information:
I give my
Permiso para revelar informacion: Doy mi permiso al
permission to the County Welfare Department to release
departamento de bienestar del condado para que revel
this information to _____________________________.
información a _________________________________.
(Provider’s name)
(Nombre del Proveedor)
__________________________________________________________
(Applicant’s signature) (Firma del solicitante)
MC 174 English/Spanish (05/07)
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