Form Mc 221 La - Disability Determination And Transmittal
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2State of California—Health and Human Services Agency
Department of Health Care Services
PLEASE PRINT
County Welfare Department Address
Retain Copy 4
(Send copies 1, 2, and 3 to DDSD)
DO NOT MAIL TO APPLICANT
County number
Aid code
Case number
—
—
1. Applicant name (first)
(middle name)
(last)
DDSD Address
DDSD-Los Angeles State Programs
2. Social Security number
3. Date of birth
P.O. Box 992
El Segundo, CA 90245-0992
–
–
–
–
Month
Day
Year
Pending
None
Male
Female
4. Sex
5. Date applied
6. List retro month(s)
7. Mailing address
–
–
___/___ ___/___ ___/___
Month
Day
Year
Month/Year
Month/Year
Month/Year
8. Type of referral (check appropriate box(es))
Initial referral
IHSS
Retro-onset
–
Redetermination
SGA IHSS
Limited referral
Telephone number:
Reevaluation
SGA-disabled
Other—explain (item 10)
(area code)
Pickle-blind
CAPI
9. Is applicant in a hospital?
Yes
No
Reexamination
Resubmitted packet
Name of hospital:
10. County worker comment(s) (If more space is needed, attach a separate sheet.)
See attached sheet (e.g., DHCS 7045)
(MC 179) 90-Day Status Letter attached
Presumptive Disability approved
11. File reviewed and approved for transmittal
Worker number
Print worker name
Telephone number
FAX number
12. Date sent
–
–
–
–
Month
Day
Year
(area code)
(area code)
MC 179 (90 Day Status Letter attached)
Presumptive disability approved
DDSD USE ONLY
13.
See attached DDSD Documents (This is NOT a certification for in-home supportive services.)
Comment(s) or SP-DDSD Presumptive Disability decision
14. Analyst
15. Date
16. Team manager
17. Date
DISABILITY DETERMINATION AND TRANSMITTAL
Oakland
Los Angeles
SEE BACK OF COPY 4
MC 221 LA (02/14)
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