Form Dhcs 7102 - Notice Regarding Standards For Medi-Cal Eligibility And Recovery Page 3

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State of California—Health and Human Services Agency
Department of Health Care Services
1. In some circumstances, Medi-Cal does not count funds held in an IRA, Keogh, or
other work-related retirement arrangement.
To find out if Medi-Cal would count your IRA, Keogh, or work-related retirement
arrangements, you may contact your local county welfare department.
I have read the above notice and have received a copy.
_____________________________________________________________________
Purchaser signature
Date
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_____________________________________________________________________________________________
Spouse’s signature
Date
➤
_____________________________________________________________________________________________
Legal representative signature
Date
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_____________________________________________________________________________________________
DHCS 7102 (01/18) ENG

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