Form Dhcs 7035 C - California Medical Report On Child With Allegation Of Human Immunodeficiency Virus Infection - Health And Welfare Agency Page 2
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6What We Mean By “Marked” (see Item D.2.c—Applies Only to Children Age 3 to 18):
When “marked” is used to describe functional limitations, it means more than moderate, but less than extreme. “Marked” does not imply that your
patient is confined to bed, hospitalized, or placed in a residential treatment facility.
A marked limitation may be present when several activities or functions are impaired or even when only one is impaired. An individual need not be
totally precluded from performing an activity to have a marked limitation, as long as the degree of limitation is such as to seriously interfere with the
ability to function independently, appropriately, and effectively in an age-appropriate manner.
PRIVACY ACT NOTICE
The Department of Health Care Services (DHCS) is authorized to collect the information on this form
under Sections 205(a), 233(d), and 1633(e)(1) of the Social Security Act. The information on this form is
needed by DHCS to make a decision on the named applicant’s application for Medi-Cal based on disability.
While giving us the information on this form is voluntary, failure to provide all or part of the requested information
could prevent an accurate or timely decision on the named applicant’s application. Although the information
you furnish is almost never used for any purpose other than making a determination about the applicant’s
disability, such information may be disclosed by DHCS as follows: (1) to enable a third party or agency to
assist DHCS in establishing rights to Medi-Cal benefits, and (2) to facilitate statistical research and audit
activities necessary to assure the integrity and improvement of the Medi-Cal program.
We may also use the information you give us when we match records by computer. Matching programs
compare our records with those of other federal, state, and local government agencies. Many agencies may
use matching programs to find or prove that a person qualifies for benefits paid by the Federal Government.
The law allows us to do this even if you do not agree to it.
Federal law governing Medicaid requires that medical information on applicants and beneficiaries be kept
confidential. [(42 United States Code, Section 139a (a) (7).)] The regulations implementing this law deal with
the disclosure of information collected and maintained by state Medicaid agencies. (42 California Federal
Register, Sections 431.300 et seq.)
DHCS 7035 C(Coversheet) (04/08)
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