Medi-Cal Status Report - State Of California - Health And Human Services Agency Page 6
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9State of California - Health and Human Services Agency
Department of Health Care Services
DO NOT SEND ANY DOCUMENTS WITH THIS FORM
Section 2:
Check “Yes” for all changes in the last 6 months and explain
Income Changes
p
Yes
Did you or a family member in the home get more or less money from a job, child support or alimony, social
security, veteran benefits, unemployment or disability benefits, retirement, gifts or interest or dividends?
Please Explain:
Expenses Paid Changes
p
Yes
Have you or any family member in the home changed the amount paid for child or adult care, health
insurance, court-ordered child support, alimony or educational expenses?
Please Explain:
Living Situation Changes
p
Yes
Did anyone move into or out of your home, move in with someone else, get married, or have a baby?
Please Explain:
If yes, do they want Medi-Cal? [ ] Yes [ ] No
Other Changes
p
Yes
Did someone in your household have a change in the amount of property they have (for example; money in
bank accounts, vehicles, real estate, etc.), their immigration status or other health insurance benefits?
Please Explain:
Disabled
p
Yes
Has anyone in your household become mentally or physically disabled? If yes, who?
Pregnant
p
Yes
Has anyone in your household become pregnant? If yes, who?
What is the expected due date?
How many babies are expected?
Section 3:
Signature and Certification
I understand that I must report all changes in income, property, and/or other changes to the county. I declare under
penalty of perjury that all information provided above is true and correct.
Signature:______________________________ Phone: (
)_________________ Date:____________
Witness Signature:________________________ Phone: (
)_________________ Date:____________
(If person signed with a mark)
Signature of person
Relationship to
acting for Beneficiary:__________________________Beneficiary_______________ Date:______________
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