Medi-Cal Status Report - State Of California - Health And Human Services Agency Page 5
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9State of California - Health and Human Services Agency
Department of Health Care Services
MEDI-CAL STATUS REPORT
ATTENTION: STATE LAW REQUIRES YOU TO COMPLETE A MID-YEAR STATUS REPORT
YOU MUST RETURN THIS FORM BY_____________ TO KEEP YOUR MEDI-CAL. PLEASE PRINT AND USE INK.
Notice Date: _________________________________
Case Number: ________________________________
Worker Name: ________________________________
Worker Number: ______________________________
Worker Telephone Number: _____________________
Office Hours: _________________________________
Do not fill out this form if the only persons in your family receiving Medi-Cal are aged 65 or older,
blind, children under the age of 21, CalWORKs recipients or someone who has already reported their
pregnancy or disability to their Medi-Cal worker.
To keep your Medi-Cal, you are required to fill out this form if you are a parent who receives
Medi-Cal. Tell us about changes you have had in the last 6 months. If you need help filling out this form,
call your worker. Your worker’s name and telephone number are listed above.
Section 1:
If you have no changes to report in the last 6 months:
• Review items listed in Section 2 (go to back side).
p
•
If no changes to report, check this box
No Changes
• Do NOT fill out Section 2.
• Go to Section 3 on back side. You must sign and date this form.
• Return the completed form to the county by the date on the top of this page.
• Use the enclosed pre-addressed envelope. No stamps are needed.
If you DO have changes to report in the last 6 months
• Go to the back side. Fill out Section 2.
• Go to Section 3. You must sign and date this form.
• Return the completed form to the county by the date on the top of this page.
• Do not send any documents.
• Use the enclosed pre-addressed envelope. No stamps are needed.
REMEMBER: You must sign the back of this form
GO TO BACK SIDE u
MC 176 S (English) (03/09)
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