COUNTY OF SAN BERNARDINO

Date: 01/13/2023
Victorville TAD/WTW/Child Care/PID
15010 PALMDALE RD
VICTORVILLE, CA 92392-2546
Case Name: Manuel S Chavez
Case Number: 1571124
Worker Name: Victorville Cont MCCF
Worker ID: 36LS18MN11
Worker Phone Number: (877) 410-8829

MANUEL S CHAVEZ
15105 CONDOR RD
VICTORVILLE, CA 92394-2105

0000000370843358
Page 1 of 37
 COUNTY OF SAN BERNARDINO
Date: 01/13/2023
Case Name: Manuel S Chavez
Case Number: 1571124
Worker Name: Victorville Cont MCCF
Worker ID: 36LS18MN11
FIRST-CLASS MAIL PERMIT NO. 1372 SAN BERNARDINO CA
POSTAGE WILL BE PAID BY ADDRESSEE Worker Phone Number: (877) 410-8829

Victorville TAD/ESP/Child Care/PID

SAN BERNARDINO COUNTY HUMAN SERVICES
15010 PALMDALE RD
VICTORVILLE, CA 92392-9923

0000000370843358
Page 2 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES

You may lose

your Medi-Cal if
Medi-Cal Renewal Form you do not
You can get this form in another language or accessible format of your choice. respond by
To ask for help in your language, call: 03/10/2023
1- (877) 410-8829 (TTY: 1- (800) 952-8349 ).

15105 CONDOR RD Notice date: 01/13/2023

VICTORVILLE, CA 92394-2105 Case number: 1571124
Case name: Manuel S Chavez
Worker name: Victorville Cont MCC
Worker telephone number: (877) 410-8829

It’s time to renew benefits for:

Name Date of birth

Manuel S Chavez 11/07/1975

Household members not on this form will get a separate letter about their Medi-Cal.

Step 1. Read the form and answer the questions

Step 2. Sign and date on the Declaration and Signature page
Step 3. Send the form with proof by the due date of 03/10/2023

Easy ways to give us your form and proof:

Online By mail By phone In person
at www.benefitscal.org in the envelope that at 1- (877) 410-8829 to Victorville TAD/WTW/Child Care/PID
or coveredca.com. came with this (TTY: 1- (800) 952-8349 ).
letter.
at 15010 PALMDALE RD
VICTORVILLE, CA 92392-2546

They are open

Monday through Friday,
?
Questions? Call your local county office at
[1- (877) 410-8829 ] before the due date. 08:30 AM to 04:30 PM

MC 216 ENG (Rev 10/20)

0000000370843358
Page 3 of 37
Your contact information
Review your information Update or add new information below
This information is correct. I have updated my information below. Only write
If correct, go to page 3. in new or changed information.
Name Name (first, middle, last)
Manuel S Chavez
Home address Home address Apartment #
15010 PALMDALE RD
VICTORVILLE, CA 92392-2546 City State ZIP code

Mailing address (If different from home address or you

Mailing address do not have a home address)
15105 CONDOR RD
VICTORVILLE, CA 92394-2105
City State ZIP code

Phone Phone
Home:
Home - - Cell - -
Cell: (909) 630-3098
Work - - Other - -
Other:
Email Email (optional):
mancha4812@gmail.com
Language to write to you in Language we should write to you in:
English
Language to speak to you in Language we should speak to you in:
English

Best way to contact you: Email  Phone  Mail

Do you need an authorized representative?

Call your local county office at 1- (877) 410-8829
(TTY: 1- (800) 952-8349 ) if you need to:
■ Appoint an authorized representative such as a family member, friend, caretaker,
attorney, or advocate to accompany, assist, or represent you with your Medi-Cal
eligibility and enrollment
■ Change your authorized representative

MC 216 ENG (Rev 10/20)

0000000370843358
Page 4 of 37
 If you need to add more people or information in any of the
sections, please write it on a separate sheet of paper (or you can
make a copy of the page) and send it with your renewal form.

Household members
We need information about you and every member of your household.
This includes:
■ Your spouse or registered domestic partner
■ Your children who live with you
■ All parents who live in the home with their children
■ Anyone on your federal income tax return, if you file one. You don’t need to file taxes to apply for
health insurance.
■ If you are claimed as a dependent on someone else’s tax return, you must include all members
of the tax filing household that claimed you, and any family members living with you.
■ Anyone else who lives with you will need to file their own application if they want health
insurance.(For example: a boyfriend, girlfriend or roommate)

Review your household member information.

Name Relation to Address Is this correct? If
yes, go to the next
Manuel S Chavez section. If no ,
update below.

Yes No

Yes No

Yes No

continued on the next page »

MC 216 ENG (Rev 10/20)

0000000370843358
Page 5 of 37
» continued

Update or add new household member information.

Tell us about changes to your household in the last 12 months.
For example, a household member got married, had a baby, moved into or out of your home,
was incarcerated, or if there was a death in the household.

Name Relation to What changed?

(first, middle, last) [case holder’s name]

1.

2.

3.

Tax information
The primary taxpayer is the person listed first on the tax return and on this table.
Review your tax information.
Name Does this Does this What is this Is this correct? If
person plan to person person’s tax yes, go to the
file a federal tax expect to be filing status? next section. If no,
return? required to update below.
file taxes?
Primary Tax Filer

Manuel S Chavez No Primary Tax Filer Yes No

Yes No

continued on the next page»

MC 216 ENG (Rev 10/20)

0000000370843358
Page 6 of 37
» continued

Update or add new tax information.

Has your primary tax filer changed? (This is the person listed first on the tax return.)

Yes  No If yes, primary tax filer’s name:

Name Does this person Does this person What is this person’s tax
(first, middle, last) plan to file a expect to be required filing status?
federal tax return? to file a tax return?

Married filing jointly with:

Married filing separately

Single
1. Yes No Yes No Head of household
Dependent Claimed by:

Non-tax filer

Married filing jointly with:

Married filing separately

2. Single
Yes No Yes No
Head of household
Dependent Claimed by:

Non-tax filer

MC 216 ENG (Rev 10/20)

0000000370843358
Page 7 of 37
Income
Income is money you get from a job, self-employment, or other sources such as Social Security or pension.
You must attach current proof of all incomes. For example:
■ Recent pay stubs
■ Benefits or award letters
■ Last year’s tax return

Review your income information.

Name Source of Income How often? Is this correct?
income before taxes (annually, If yes, go to the next
or deductions monthly, every 2 section. If no, give the
(Federal weeks, twice a date of the last time you
taxable month, weekly, got this income. Then
income) daily, or hourly) update or add below.

Yes No
/ /

Yes No
/ /

Yes No
/ /

continued on the next page »

MC 216 ENG (Rev 10/20)

0000000370843358
Page 8 of 37
» continued

Update or add new income information.

Examples of most common income types:
■ Income from your job ■ Spousal support received:
■ Income from self-employment Fill in the most recent date or modification date of
■ Social
your divorce or separation agreement
Security retirement,
(month/day/year) here:
survivors, and disability benefits
/ /
■ Unemployment benefits

Name What is the Your income Start date How often? Is this income
(first, middle, last) source of before taxes (month, day, (annually, expected to
this or year) monthly, every 2 continue?
income? deductions weeks, twice a If no, give
(Federal month, weekly, the last date you
taxable daily,or hourly) expect to get
income) this income.

Yes No
1. $
/ /

Yes No
2. $
/ /

Yes No
3. $ / /

Does anyone’s income change from month to month?

Yes No If yes, tell us what the total income will be for the next 12 months.
This is to help get the correct annual income amount.

Name What is your total income expected

(first, middle, last) to be for the next 12 months?

1. $

2. $

MC 216 ENG (Rev 10/20)

0000000370843358
Page 9 of 37
Expenses and deductions
Reporting tax expenses and deductions that you pay, may lower the income Medi-Cal uses to determine
your eligibility. You must attach current proof of expenses and deductions. For example:
■ Profit and loss statement
■ Tax return

Review your expenses and deduction information.

Name Type of expense or Amount How often? Is this correct?
deduction (monthly, If yes, go to the next
quarterly, section.
annually) If no, update below.

$ Yes No

$ Yes No

Update or add new expenses and deductions information.

Examples of most common expenses and deductions:
■ Self-employment expenses ■ Alimony paid: Fill in the most recent date or
■ Student loan interest modification date of your divorce or separation
■ IRA contributions agreement (month/day/year) here:
/ /
Name (first, middle, last) Type of expense or Amount How often?
deduction (monthly, quarterly,
annually)

1. $

2. $

3. $

MC 216 ENG (Rev 10/20)

0000000370843358
Page 10 of 37
Other health insurance
Tell us about any health coverage that you have that is not from Medi-Cal or Medicare. For example, you
may also have health insurance from Covered California or a family member’s job.
If you do not have other health insurance, skip this section and go to the next.

Review your health insurance information.

Name Insurance Type of Premium How often Is this
company Insurance amount (monthly, correct? If
(such as health, you pay quarterly, yes, go to the
dental, vision, annually) next section. If
pharmacy) no, update
below.

$ Yes No

$ Yes No

Update or add new health insurance information.

Name Insurance Type of Premium How often
(first, middle, last) company Insurance amount (monthly, quarterly,
(such as health, you pay annually)
dental, vision,
pharmacy)

1. $

2. $

MC 216 ENG (Rev 10/20)

0000000370843358
Page 11 of 37
Household changes
Fill-in the information below if you answer yes to any of the following questions.

Medi-Cal
Does anyone in your household who is not on Medi-Cal want to apply? If yes, fill in below.
Name (first, middle, last) Date of birth Social Security number, if they have
(month/day/year) one, of the person who wants Medi-Cal
- -

Pregnant
Is anyone in your household pregnant? If yes, fill in below.
Name (first, middle, last) Due date How many babies
(month/day/year) are expected?

/ /

Former foster youth

If anyone in your household is between 18 and 26 years old, were they in foster care in any state on
or after their 18th birthday? If yes, fill in below.

Name (first, middle, last) State (example: California)

Immigration or citizenship (This information is only used to determine health coverage.)

Has anyone in your household who now has Medi-Cal had a change in their immigration or
citizenship status in the past 12 months? If yes, fill in below.

Name (first, middle, last) New status number

Disability
Does anyone in your household have a physical, mental, emotional, or developmental disability? If yes , fill
in below.
Name (first, middle, last) Is the disability a result of an
injury?
Yes  No

MC 216 ENG (Rev 10/20)

0000000370843358
Page 12 of 37
» continued

Student
Is anyone in your household 19 or 20 years old and a full-time student? If yes, fill in below.

Name (first, middle, last)

Medicare
Does anyone in your household have Medicare? If yes, fill in below.
Name (first, middle, last) Medicare number Monthly premium you
pay
$

Long-term care
Is anyone in your household in long-term care? If yes, fill in below.
Name of person in long-term care Entrance date Discharge date
(first, middle, last) (month/day/year) (month/day/year)
/ / / /

Long-term care facility name Long-term care facility address

Spouse or registered domestic partner’s name Spouse or registered domestic

(first, middle, last) partner’s address if different

MC 216 ENG (Rev 10/20)

0000000370843358
Page 13 of 37
Health program information and referrals
This section is optional. You can choose not to answer, but your answers help us refer you to available
services.

1. Do you want information on the no-cost health program for children under 21 (Child Health and
Disability Prevention Program, also known as CHDP)?

Yes  No

2. Do you want information on the no-cost supplemental food program for people who are pregnant
or breastfeeding and children under 5 (Women, Infants, and Children Program, called WIC)?

Yes  No

3. Is any household member living in the home receiving kidney dialysis-related services?

Yes  No If yes, who:

4. Has any household member living in the home received an organ transplant within the last 2
years?

Yes  No If yes, who:

5. Do you want information on the Personal Care Services Program, an in-home care program for
aged, blind, or disabled persons (also called In-Home Supportive Services)?

Yes  No

6. Does anyone in your household need help with long-term care or home and community-based
services?

Yes  No If yes, who:

MC 216 ENG (Rev 10/20)

0000000370843358
Page 14 of 37
Declaration and signature
■ I declare under penalty of perjury under the laws of the state of California that what I say below is true
and correct.
■ I understood all questions on this renewal form and gave true and correct answers as far as I know.
Where I did not know the answer myself, I made every reasonable attempt to confirm the answer with
someone who did know. I have read or had read to me the privacy statement, rights, and responsibilities
on the following pages.
■ I know that if I do not tell the truth on this renewal form, there may be a civil or criminal penalty for perjury
that may include up to four years in jail (See California Penal Code section 126). I know that the
information in this renewal form will be used to decide if the people who are applying qualify for health
insurance. The Medi-Cal program and Covered California will keep the information private, as required by
federal and California law.
■ If anything changes on this renewal form for any person applying for health insurance, I agree to notify
the Medi-Cal program or contact my local county office within 10 days of any change. If I have insurance
through Covered California, I agree to report any changes within 30 days.

Sign and date below.

Signature of applicant/beneficiary or authorized representative Date (month/day/year)

Remember to attach all current proof if

required, and all additional copies or
extra pages.

MC 216 ENG (Rev 10/20)

0000000370843358
Page 15 of 37
Keep for your records
These pages contain important information about privacy statement, rights and responsibilities, right to
appeal, and nondiscrimination policy, and filing a discrimination grievance.

Privacy statement
This renewal form is for renewing Medi-Cal benefits through the Department of Health Care Services
(DHCS) and determining eligibility for health insurance through Covered California. The personal and
medical information you provide on it is private and confidential. DHCS or Covered California needs it to
identify you and the other people on this renewal form and to administer our programs.

We will share your information with other state, federal, and local agencies, contractors, health plans, and
programs only to enroll you in a plan or program or to administer programs, and with other state and federal
agencies as required by law.

You must answer all of the questions on this renewal form unless marked “optional” or if you are directed
otherwise. If your renewal form is missing anything that we require, we will contact you to get it. If you do not
provide it, we will not be able to make a decision on your renewal. You may have to submit a new
application. Or you may not be able to get health insurance through Covered California or your application
for benefits renewal may be denied.
In most cases, you have the right to see personal information about you that is in federal and state records.
You can see it in an alternative format such as large print if you need that. For more information or to see
Covered California records, contact the Privacy Officer at:

The Department of Health Care Services Covered California

Attn: Information Protection Unit Attn: Privacy Officer
P.O. Box 997413, MS 4721 P.O. Box 989725
Sacramento, CA 95899-7413 West Sacramento, CA 95798-9725
Phone: 1-866-866-0602 Phone: 1-800-300-1506
TTY: 1-877-735-2929 TTY: 1-888-889-4500

DHCS shall comply with the requirements of 45 C.F.R. Parts 160 and 164, California Civil Code §§
1798 – 1798.78, CA Welfare and Institutions Code (WIC) Section 14005.37, CA WIC Section 14011
and Article 3, Chapters 5 and 7, Parts 2 and 3, Division 9, and other applicable laws in the storage,
use, and release of the information provided in this form.

Covered CA: 42 U.S.C. § 18031; CA Government Code §§ 100502(k) and 100503(a).

You can find the Notices of Privacy Practices for the Medi-Cal program at www.dhcs.ca.gov and for
Covered California at www.CoveredCA.com.

MC 216 ENG (Rev 10/20)

0000000370843358
Page 16 of 37
Rights and responsibilities
■ The information I gave on this renewal form is true as far as I know. I know that I may be subject to a
penalty if I do not tell the truth.

■ I understand that the information I give will be used only to see if those in my family who are applying to
renew health insurance will qualify.
■ I understand that the Medi-Cal program and Covered California will keep my information private, as the
law requires. For more information, or access to personal information in records maintained by the Medi-
Cal program and Covered California, I can contact my local county office. Or I can contact the Covered
California Privacy Officer at 1-800-300-1506 (TTY: 1-888-889-4500).
■ I understand that to be eligible for Medi-Cal, I am required to apply for other income or benefits to which
I or any member of my household is entitled, unless he or she has good cause for not doing so.
Examples of such income or benefits are pensions, government benefits, retirement income, veteran’s
benefits, annuities, disability benefits, Social Security benefits (also called OASDI or Old Age, Survivors,
and Disability Insurance), and unemployment benefits. But such income or benefits do not include public
assistance benefits, such as CalWORKs or CalFresh. If I have a question about a possible source of
income, I can call my local county office or Covered California at 1-800-300-1506 (TTY: 1-888-889-4500)
for help.
■ If I am found eligible for Medi-Cal, I must tell my county eligibility worker about any changes that may
affect my eligibility for health insurance within 10 days of the change to my local county office.
These changes include, but are not limited to:
» I move
» my income changes
» my household changes (for example, marriage/divorce, become pregnant, or have a child(ren))
» I become qualified for other health insurance
■ If I am enrolled in Covered California, I understand I must report changes within 30 days. I can call
Covered California at 1-800-300-1506 (TTY: 1-888-889-4500) or visit CoveredCA.com.
■ I understand that I must report income changes to my local county office because it may affect the
eligibility for Medi-Cal benefits or Covered California for the amount of state and federal financial help
that I may be eligible to receive. I also understand if I receive too much financial help during the benefit
year, I will have to repay the extra premium assistance or state subsidy back to the IRS or California
Franchise Tax Board when I file my federal and state income taxes for the benefit year.

■ I give my permission to Covered California and the Medi-Cal program to check other agencies computer
records to verify citizenship or whether I am lawfully present in the U.S., tax information,’and other
information related only to eligibility to see if I and other people on this renewal qualify for health
insurance.

■ I understand that as required by law, the information I provide about myself and other people on this
renewal for Medi-Cal will be checked by computer with facts given by employers, banks, SSA, Internal
Revenue Service, Franchise Tax Board, social services and other agencies to see if I or other people on
this renewal qualify for health insurance.

MC 216 ENG (Rev 10/20)

0000000370843358
Page 17 of 37
 ■ I know that if Medi-Cal pays for a medical expense, any money I or anyone on this renewal form gets
from other health insurance or legal settlements related to that expense will go to Medi-Cal as payment
for the expense until the expense is paid in full.
■ For parents whose child or children qualify for Medi-Cal: I know I will be asked to help the agency that
collects medical support from any parent on this renewal form who does not live with the child and does
not send support for the child. If I think that helping will harm me or my children, I can tell the Medi-Cal
program and I will not have to help.

Right to Appeal
If I think the Medi-Cal program or Covered California has made a mistake, I can appeal its decision.
To appeal means to tell someone at the Medi-Cal program or Covered California that I think its decision is
wrong and ask for a fair review of the action.

I know that I must file an appeal within 90 days of the decision. I know that I can represent myself or have
someone else represent me in my appeal, such as an authorized representative, a friend, a relative, or a
lawyer.
I know that if I need help, someone at the Medi-Cal program, Covered California, or the local county office
can explain my case to me.
California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430
Fax: 1-833-281-0905
Toll free: 1-855-795-0634 or
Public Inquiry and Response toll free: 1-800-952-5253 or TDD 1-800-952-8349

Nondiscrimination Policy
The Medi-Cal program (DHCS) and Covered California comply with applicable federal and state civil rights
laws and do not unlawfully discriminate on the basis of race, color, religion, ancestry, national origin, ethnic
group identification, age, mental disability, physical disability, medical condition, genetic information, marital
status, sex, gender, gender identity, or sexual orientation.
The Medi-Cal program (DHCS) and Covered California do not unlawfully exclude people or treat them
differently because of race, color, religion, ancestry, national origin, ethnic group identification, age, mental
disability, physical disability, medical condition, genetic information, marital status, sex, gender, gender
identity, or sexual orientation.
The Medi-Cal program (DHCS) and Covered California provide free aids and services to people with
disabilities to communicate effectively with us, such as qualified sign language interpreters and written
information in other formats (large print, audio, accessible electronic formats, and other formats).

The Medi-Cal program (DHCS) and Covered California also provide free language services to
people whose primary language is not English, such as qualified interpreters and information written

MC 216 ENG (Rev 10/20)

0000000370843358
Page 18 of 37
in other languages. If you need these services, contact the DHCS Office of Civil Rights at 1-916-440-7370,
(Ext. 711, California State Relay) or email CivilRights@dhcs.ca.gov, or contact Covered California at
1-800-300-1506 (TTY: 1-888-889-4500).

Filing a Discrimination Grievance

If you believe that the Medi-Cal program (DHCS) or Covered California has failed to provide these services
or you have been discriminated against in another way on the basis of race, color, religion, ancestry,
national origin, ethnic group identification, age, mental disability, physical disability, medical condition,
genetic information, marital status, sex, gender, gender identity, or sexual orientation, you can file a
grievance with the Medi-Cal program’s (DHCS’s) Office of Civil Rights or the Covered California Civil Rights
Coordinator: 

Medi-Cal Program (DHCS) Covered California

Office of Civil Rights Civil Rights Coordinator
P.O. Box 997413, MS 0009 P.O. Box 989725
Sacramento, CA 95899-7413 West Sacramento, CA 95798-9725
Phone: 1-916-440-7370 Phone: 1-916-228-8764
(Ext. 711, CA State Relay) Fax: 1-916-228-8909
Email: CivilRights@dhcs.ca.gov Email: CivilRights@covered.ca.gov
Medi-Cal complaint forms are available at:
www.dhcs.ca.gov/Pages/Language.Access.aspx

You can also file a separate civil rights complaint with the federal Office for Civil Rights at the U.S.
Department of Health and Human Services. You can do this if you believe you have been discriminated
against on the basis of race, color, national origin, age, disability, or sex:

U.S. Department of Health and Human Services

Mail: 200 Independence Ave. SW Room 509F
HHH Building, Washington, DC 20201
Phone: 1-800-368-1019 (TTY: 1-800-537-7697)
Online Complaint Portal Assistant: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Online Complaint forms: https://ocrportal.hhs.gov/ocr/cp/wizard_cp.jsf

MC 216 ENG (Rev 10/20)

0000000370843358
Page 19 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES

Medi-Cal Information for Beneficiaries

You are receiving the enclosed information because you are eligible for Medi-Cal. Medi-Cal is required to provide
these materials every year. You are not required to return any of these materials to be eligible for Medi-Cal. The
materials in this packet will provide you with information about Medi-Cal and your rights as a Medi-Cal beneficiary.
Please make sure to carefully review all documents enclosed in this packet. If you have any questions, contact your
Eligibility Worker. Or contact you local county social services office, which can be found at:
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (English)

Está recibiendo la información adjunta porque reúne los requisitos para recibir Medi-Cal. Medi-Cal está obligado a
proporcionarle estos materiales cada año. No es necesario que devuelva ninguno de estos materiales para tener
derecho a recibir Medi-Cal. Los materiales en este paquete le proporcionan información sobre Medi-Cal y sus
derechos como beneficiario de Medi-Cal. Asegúrese de revisar detenidamente todos los documentos incluidos en
este paquete. Si tiene alguna pregunta, comuníquese con su trabajador de elegibilidad. O comuníquese con la
oficina local de servicios sociales de su condado, la cual puede encontrar en:
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (Spanish)

‫ ﻟﺳت ﻣطﺎﻟﺑًﺎ ﺑﺈﻋﺎدة أي‬.‫ ﺗوﻓﯾر ھذه اﻟﻣواد ﻛل ﻋﺎم‬Medi-Cal ‫ وﯾﺟب ﻋﻠﻰ‬.Medi-Cal ‫ﺗﺗﻠﻘﻰ اﻟﻣﻌﻠوﻣﺎت اﻟﻣرﻓﻘﺔ ﻷﻧك ﻣؤھل ﻟﺑرﻧﺎﻣﺞ‬
Medi-Cal ‫ ﺳوف ﺗزودك اﻟﻣواد اﻟﻣدرﺟﺔ ﻓﻲ ھذه اﻟﺣزﻣﺔ ﺑﻣﻌﻠوﻣﺎت ﺣول‬.Medi-Cal ‫ﻣن ھذه اﻟﻣواد ﺣﺗﻰ ﺗﻛون ﻣؤھﻼً ﻟﺑرﻧﺎﻣﺞ‬
‫ وإذا ﻛﺎﻧت ﻟدﯾك أﯾﺔ‬.‫ ﯾرﺟﻰ اﻟﺗﺄﻛد ﻣن ﻣراﺟﻌﺔ ﺟﻣﯾﻊ اﻟﻣﺳﺗﻧدات اﻟﻣرﻓﻘﺔ ﺑﮭذه اﻟﺣزﻣﺔ ﺑﻌﻧﺎﯾﺔ ﺑﺎﻟﻐﺔ‬.Medi-Cal ‫وﺣﻘوﻗك ﻛﻣﺳﺗﻔﯾد ﻣن‬
‫ واﻟذي ﯾﻣﻛﻧك اﻟﻌﺛور‬،‫ أو اﺗﺻل ﺑﻣﻛﺗب اﻟﺧدﻣﺎت اﻻﺟﺗﻣﺎﻋﯾﺔ اﻟﻣﺣﻠﻲ ﻓﻲ اﻟﻣﻘﺎطﻌﺔ‬.‫ ﺗﻔﺿل ﺑﺎﻻﺗﺻﺎل ﺑﺄﺧﺻﺎﺋﻲ اﻻﺳﺗﺣﻘﺎق‬،‫ﺗﺳﺎؤﻻت‬
(Arabic) www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx : ‫ﻋﻠﯾﮫ ﻋﻠﻰ‬

Դուք ստանում եք կից տեղեկությունները, քանի որ համապատասխանում եք «Medi-Cal»-ի պահանջներին։ «Medi-Cal»-ը պարտավոր է աﬔն
տարի տրամադրել այս տեղեկությունները։ «Medi-Cal»-ի իրավասության համար Ձեզանից չի պահանջվում վերադարձնել այս նյութերից որևէ
ﬔկը։ Այս փաթեթում պարունակվող նյութերը տեղեկություններ են պարունակում «Medi-Cal»-ի և որպես «Medi-Cal»-ի նպաստառու՝ Ձեր
իրավունքների մասին։ Խնդրում ենք ուշադրությամբ ծանոթանալ այս փաթեթում պարունակվող բոլոր փաստաթղթերին։ Հարցերի դեպքում դիﬔք
իրավասության հարցերով Ձեր աշխատակցին։ Կամ դիﬔք Ձեր շրջանի սոցիալական ծառայությունների գրասենյակ, որը կարելի է գտնել
հետևյալ հասցեում․ www.dhcs.gov/services/medi-cal/Pages/CountyOffices.aspx (Armenian)

េកអកកំពុងទទួលព័ត៌នែដលន
 ប់ម
ួ យ េយរែតេកអកនស
ិ ិ ទច
ូ លរ
ួ ម Medi-Cal។ Medi-Cal ្រត
� វ នត្រម
� វឱ្យផ
 ល់ឯករ
ំ ងេនះេរងល់
ំ ។
េកអកម
ិ ន្រត
� វនត្រម ី ្រតឡប់មកវ
� វឱ្យេផ ិ ញន
ូ វឯករ
ំ ងេនះ េឡ ី ម្ប
ី យ េដ ី នស
ិ ិ ទច
ូ លរ
ួ ម Medi-Cal។ ឯករេកុងេ្រមសំបុ្រតេនះន
ឹ ងផ
 ល់ឱ្យេកអកន
ូ វព័ត៌នអំព
ី
Medi-Cal ិ នងស  ្របេជន៍ Medi-Cal។ ស
ិ ិ ទរបស់េកអក កុងមអកទទួលអត ូ ម្រកដ េកអកព
ិ ិ នត្យេយ្របុង្របយ័ត
ូនវឯករ
ំ ងអស់ ែដលន
 ប់ម
ួ យេកុងេ្រមសំបុ្រតេនះ។ េប
ី េកអកនសំណ
ូ រម
ួ យស
ូ មក់ទងអក េធ
ី  រែផកស
ិ ិ ទច
ូ លរ
ួ មរបស់េកអក។
ឬស
ូ មក់ទងរ
ិ ល័យេសកមសង
 មក
ិ ច
 េនធ
ី មតំបន់របស់េកអក ែដលចរកេឃ
ី ញេ៖
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (Cambodian)

您現在收到隨附的資訊是因為您有資格享受Medi-Cal。Medi-Cal每年都必須提供這些資料。您不需要為了
能享受Medi-Cal而將這些資料中的任何部分寄還給我們。本資料包內的資料將為您提供有關Medi-Cal的資
訊以及您作為Medi-Cal受益人而享有的權利。請務必仔細查閱本資料包內隨附的所有文檔。如果您有任何
疑問，請跟您的資格管理人員聯繫。或者跟您當地的縣社會服務辦公室聯繫，縣社會服務辦公室聯繫資
訊可在www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx找到。(Chinese)

MC Information Notice 019 (02/15)

0000000370843358
Page 20 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES

‫ ﻣﻠزم اﺳت ﺗﺎ اﯾن‬Medi-Cal ‫ ھر ﺳﺎل‬.‫ را دارﯾد‬Medi-Cal ‫اطﻼﻋﺎت ﺿﻣﯾﻣﮫ ﺷده ﺑﮫ ﺷﻣﺎ ارﺳﺎل ﻣﯽ ﺷود زﯾرا ﺷﻣﺎ ﺻﻼﺣﯾت ﺑرﺧورداری از‬
‫ ﻣطﺎﻟب اﯾن ﺑﺳﺗﮫ در ﻣورد‬.‫ ﻣﻠزم ﺑﮫ ارﺳﺎل ھﯾﭼﯾﮏ از اﯾن ﻣطﺎﻟب ﻧﯾﺳﺗﯾد‬Medi-Cal ‫ ﺑرای داﺷﺗن ﺻﻼﺣﯾت ﺑرﺧورداری از‬.‫ﻣطﺎﻟب را ﻓراھم ﻧﻣﺎﯾد‬
‫ ﻟطﻔﺎ ً اطﻣﯾﻧﺎن ﮐﺳب ﮐﻧﯾد ﮐﮫ ﺗﻣﺎﻣﯽ ﻣطﺎﻟب ﺿﻣﯾﻣﮫ ﺷده در‬.‫ ﺑﮫ ﺷﻣﺎ اطﻼﻋﺎت اراﺋﮫ ﻣﯽ دھﻧد‬Medi-Cal ‫ و ﺣﻘوق ﺷﻣﺎ ﺑﮫ ﻋﻧوان ذﯾﻧﻔﻊ‬Medi-Cal
‫ ﯾﺎ ﺑﺎ دﻓﺗر ﻣﺣﻠﯽ ﺧدﻣﺎت اﺟﺗﻣﺎﻋﯽ ﺧود ﺗﻣﺎس‬.‫ ﺑﺎ ﻣددﮐﺎر ﺗﻌﯾﯾن ﺻﻼﺣﯾت ﺧود ﺗﻣﺎس ﺑﮕﯾرﯾد‬،‫ اﮔر ﺳؤاﻟﯽ دارﯾد‬.‫اﯾن ﺑﺳﺗﮫ را ﺑﮫ دﻗت ﻣطﺎﻟﻌﮫ ﮐرده اﯾد‬
(Farsi) www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx :‫ ﮐﮫ ﻣﯽ ﺗوان در وﺑﺳﺎﯾت ذﯾل ﯾﺎﻓت‬،‫ﺑﮕﯾرﯾد‬

Koj tau txais cov ntaub ntawv uas nrog nov vim tias koj tsim nyog rau Medi-Cal. Medi-Cal yuav tsum tau muab cov
ntaub ntawv no rau koj txhua xyoo. Koj tsis tas yuav xa cov ntaub ntawv no rov qab kom thiaj li tsim nyog rau Medi-
Cal. Cov ntaub ntawv hauv pob ntawv no yuav qhia rau koj txog Medi-Cal thiab koj cov cai ua ib tug neeg tau kev
pab los ntawm Medi-Cal. Thov ua tib zoo saib tag nrho cov ntaub ntawv nyob hauv pob ntawv no. Yog tias koj muaj
lus nug, hu rau koj Tus Neeg Saib Xyuas Txog Kev Tsim Nyog. Los sis hu rau koj lub nras lub chav fai muab kev
pab neeg, uas yuav nrhiav tau nyob rau ntawm:
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (Hmong)

귀하는 Medi-Cal 자격이 있기 때문에 이 동봉된 자료를 받고 계십니다. Medi-Cal은 매년 이러한 자료를 보내드리도록
되어 있습니다. 어느 것이든, Medi-Cal 자격을 위해 이 자료를 제출하실 필요는 없습니다. 이 패킷의 자료에서 Medi-Cal
에 대한 정보와 Medi-Cal 수혜자로서의 귀하의 권리에 대한 정보를 알려드립니다. 이 패킷에 동봉된 모든 자료를 잘 읽
어주십시오. 질문이 있으시면 귀하의 자격심사 담당자에게 연락하십시오. 또는 귀하 카운티의 사회복지사무소에 연락
하십시오. 사회복지사무소는 다음 링크에서 찾아볼 수 있습니다:
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (Korean)

Вы получили прилагаемые документы, поскольку имеете право на участие в программе Medi-Cal. Medi-Cal
обязана предоставлять такие материалы каждый год. Вам не нужно их возвращать, чтобы сохранить право на
участие в программе Medi-Cal. В данном комплекте Вы найдете информацию о программе Medi-Cal и о своих
правах в качестве участника программы Medi-Cal. Просим внимательно ознакомиться со всеми прилагаемыми
документами. Если у Вас возникнут вопросы, свяжитесь с местным сотрудником по определению наличия
права на участие или с окружным отделом социального обеспечения. Их можно найти через веб-сайт:
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (Russian)

Natatanggap mo ang nakalakip na impormasyon dahil nararapat ka para sa Medi-Cal. Inaatasan ang Medi-Cal na
ilaan ang mga materyales na ito taon-taon. Hindi mo kailangang isauli ang anumang materyales na ito para maging
eligible sa Medi-Cal. Ang materyales sa paketeng ito ay magbibigay sa iyo ng impormasyon tungkol sa Medi-Cal at
sa mga karapatan mo bilang benepisyaryo ng Medi-Cal. Pakitiyak na maingat na i-review ang lahat ng mga
dokumentong nakalakip sa paketeng ito. Kung mayroon kang anumang mga tanong, makipag-ugnayan sa iyong
Eligibility Worker. O makipag-ugnayan sa lokal mong opisina ng social services ng county na mahahanap sa:
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (Tagalog)

Quý vị nhận được thông tin kèm theo vì quý vị hội đủ điều kiện nhận Medi-Cal. Medi-Cal bắt buộc phải cung cấp các
tài liệu này hàng năm. Quý vị không bắt buộc phải gửi lại bất kỳ tài liệu nào trong số này mới hội đủ điều kiện nhận
Medi-Cal. Các tài liệu trong tập hồ sơ này sẽ cung cấp cho quý vị thông tin về Medi-Cal và các quyền của quý vị với
tư cách là người hưởng phúc lợi Medi-Cal. Vui lòng xem kỹ tất cả các tài liệu kèm theo trong tập hồ sơ này. Nếu quý
vị có thắc mắc, liên lạc với Nhân Viên phụ trách Tình Trạng Hội Đủ Điều Kiện của quý vị. Hoặc liên lạc với văn phòng
ty xã hội quận tại địa phương quý vị, địa chỉ có trên:
www.dhcs.ca.gov/services/medi-cal/Pages/CountyOffices.aspx (Vietnamese)

MC Information Notice 019 (02/15)

0000000370843358
Page 21 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES

KEEP THIS FOR YOUR RECORDS

What you need to know when you apply for

and enroll in Medi-Cal
When I apply for Medi-Cal, how will my information be used?

County social services offices and/or Covered California will ask for personal information about
you to decide if you, or a person you are responsible for, qualify for Medi-Cal benefits. You must
give this personal information to get Medi-Cal benefits.

To read about your

The personal information gathered about you may be used in the following ways:
privacy rights and
Medi-Cal, see the
• By Covered California • By the United States • By medical services
and the county social Department of Health and providers and Health Department of Health
services office to find Human Services for audits Maintenance Care Services Notice of
out if you are eligible and quality control reviews Organizations Privacy Practices.
for Medi-Cal or and to verify Social Security (HMOs) to confirm that
enrollment into Numbers (SSNs). you qualify for services. You can find it at:
Covered California.
www.dhcs.ca.gov/
• By the State's • To verify immigration status • To identify other health formsandpubs/ laws/
administrative vendors with the Department of insurance coverage and priv/Pages/
to process claims and/or Homeland Security (DHS), if to recover costs when
NoticeofPrivacy
premium payments and required. Information shared necessary. In other
to issue Benefits with DHS cannot be used for ways, but only if required Practices.aspx
Identification Cards immigration enforcement by law.
(BICs). unless you are committing
fraud.

What are my rights when I apply for Medi-Cal?

1. You have a right to fair and equal treatment You can make a complaint by calling the
regardless of race, color, national origin, Department of Health Care Services (DHCS),
religion, age, sex, sexual orientation, Office of Civil Rights at 1-916-440-7370
gender identity, marital status, political (TTY: 1-916-440-7399) or by going online at:
beliefs, veteran's status or disability. www.dhcs.ca.gov/Documents/ADA_Title_
VI_Discrimination_Complaint_Form.docx
You have a right to file a complaint if
you think that the Medi-Cal program has
discriminated against you or has failed to
provide the reasonable accommodations
required by state and federal law.

MC 219 (11/15) ENG1

0000000370843358
Page 22 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
2. You have the right to be evaluated to see if you may be
eligible for any Medi-Cal program.
3. You have the right to information about the
Medi-Cal program and help applying for
Medi-Cal.
4. You have a right to an interpreter if you need help
applying for Medi-Cal, have questions, or have difficulty
speaking, reading or understanding English.
5. You have a right to a face-to-face interview with a county
social services worker.
6. If you think you are disabled, you can ask that Medi-Cal
review your application to see if you qualify for coverage
for disabled persons.
7. If you received health services in the three months
before the month of your application, you have a right to
be evaluated to see if you are eligible for Medi-Cal to pay
for those services. This is called retroactive eligibility.
Contact your county social services office to find out
more or ask for retroactive eligibility.
8. You have a right to be told in writing whether you qualify
for Medi-Cal or whether there are any changes to your
eligibility status.
9. You have a right to have all the information you give to
the county social services office or Covered California
kept confidential. You can look at the personal
information during your county social service office's
regular office hours.
10. You have a right to an "immediate need" Medi-Cal card if
you are eligible and have a medical emergency or you
are pregnant.
MC 219 (11/15) ENG2
DEPARTMENT OF HEALTH CARE SERVICES
11. You have a right to get Medi-Cal while waiting for your
immigration status to be verified, if you meet all other
eligibility requirements.
12. You have a right to choose the Medi-Cal health plan
you want if there is more than one Medi-Cal plan
offered in your county of residence.
13. By giving Medi-Cal past medical bills that you still owe,
you can lower your Share Of Cost (SOC), if any. For
more information about SOC, please contact your
county social services office.
14. If your property counts toward qualifying for Medi-Cal
benefits, you have the right to reduce your property to
meet the Medi-Cal property limit by the last day of the
month that you applied for Medi-Cal. The county social
services worker can tell you more information about
the property limit and meeting property requirements.
15. If you, or your spouse, enter a long-termcare facility on
or after January 1, 1990, you and your spouse have
the right to be told by the Medi-Cal program the
amount of separate and community property you can
keep and still be eligible for Medi-Cal.
16. You have a right to a state hearing if your application
for Medi-Cal benefits has not been timely determined.
Medi-Cal is required to determine your eligibility within
45 days of the date of your application, or 90 days if
the basis of your eligibility is a disability, unless you
have been asked to provide additional information and
have not yet done so.
0000000370843358
Page 23 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
• If you want a state hearing on the timeliness of your
Medi-Cal eligibility determination, you must ask for it.
You may ask for a hearing on the timeliness of your
Medi-Cal eligibility determination any time after the
45th or 90th day has passed.
• You can ask for a hearing by
1) contacting your nearest county social services
office; 2) calling the Department of Social Services at
1-855-795-0634 or TDD 1-800-952-8349; or 3)
making the request in writing to your county social
services office. You may complete the back section
on a Notice of Action (form NA Back 9) to request a
hearing and send the form, or other written request,
to your nearest county social services office. The
form is available through your county social services
office or at www.dss.cahwnet. gov/Forms/English/
NABACK9.PDF.
17. You have a right to a state hearing if you are not
satisfied with decision by the local county social
services office, DHCS, or Covered California, except
relating to the Health Insurance Premium Payment
(HIPP) program. HIPP is not an entitlement program;
therefore, there are no appeal rights for HIPP.
• If you want a state hearing to appeal the decision,
you must ask for it within 90 days of the date the
Notice of Action (NOA) was given or mailed to you.
• If you do not get a NOA, you must ask for a hearing
within 90 days from the date you discovered the
action or inaction you are not satisfied with unless
the inaction is due to a delay in determining
your application for Medi-Cal benefits.
MC 219 (11/15) ENG3
DEPARTMENT OF HEALTH CARE SERVICES
• You can ask for a hearing by
1) contacting your nearest county social services
office; 2) calling the Department of Social Services at
1-855-795-0634 or TDD 1-800-952-8349; or 3) making
the request in writing to your county social services
office. You may complete the back section on the NOA
(form NA Back 9) to request a hearing and send the
form, or other written request, to the location or fax
number on the form. You may also visit your local
county social services office and submit your request
for appeal. The form is available through your county
social services office or at www. dss.cahwnet.gov/
Forms/English/ NABACK9.PDF.
18. You have a right to review your Medi-Cal file and all
Medi-Cal program rules and regulation manuals that
were used to decide if you are eligible for Medi-Cal.
19. You have a right to information about these programs
and help getting these services:
• Child Health and Disability Prevention
Program
• Special Supplemental Food Program for
Women, Infants, and Children
• Personal Care Services Program
• Early and Periodic Screening, Diagnosis
and Treatment Program
Family Planning Access Care and
•
Treatment Program
0000000370843358
Page 24 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
20. You can talk to a social worker or county social
services worker about other public or private services
or resources such as CalFresh and CalWORKs.
What are my responsibilities if I get
Medi-Cal?
You must tell your county social services worker about
any of the following changes that have occurred within
10 days of the change:
1. You or a family member in your household has a
change in income. This applies if the income goes up
or down or starts or stops. This includes income from
the Social Security Administration (SSA), loans,
settlements, employment, unemployment and any
other source.
2. You change your home or mailing address.
3. A person moves into or out of your home, whether or
not the person is related to you or your family. This
includes newborns and foster children.
4. You or a family member in your household gives birth,
becomes pregnant, or ends a pregnancy.
5. You, your spouse, or any family member in your
household enters or leaves a nursing home or a long-
term-care facility.
MC 219 (11/15) ENG4
DEPARTMENT OF HEALTH CARE SERVICES
6. You receive, transfer, give away, or sell real or personal
property (including money), or open or close any bank
accounts. This requirement only applies if property is
counted for the Medi-Cal program you are enrolled in or
are being evaluated for. You must also report if someone
gives you or a family member in your household things
such as a car, house or insurance payments.
7. You have expenses paid for by someone else.
8. Your or a family member in your household gets a job,
changes jobs or no longer has a job.
9. You have a change in expenses related to your job or
education, such as child care or transportation.
10. You or a family member in your household, including
children, becomes physically or mentally disabled.
11. You or a family member in your household
applies for or receive disability benefits with the
SSA, Veterans Administration or Railroad
Retirement.
12. You or a family member in your household who is applying
for or getting Medi-Cal has a change in citizenship or
immigration status.
13. You or a family member in your household has a change in
health insurance coverage.
14. If you are enrolled in the Medi-Cal program for former
foster youth, tell your worker if your home or mailing
address changes. You do not need to tell your worker
about other changes, such as changes to your income, job,
or expenses.
0000000370843358
Page 25 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES

You also must: 5. Apply for Medicare, if you are eligible.

1. Give proof that you are a resident of California, when
you are asked for it.
2. Declare your citizenship or immigration status, when you
are applying for Medi-Cal.
6.
3. Give a Social Security Number (SSN) for
anyone who is applying for Medi-Cal benefits.
7.
• If you are a United States (U.S.) Citizen, a U.S.
national, or a person with satisfactory immigration
status, you must provide an SSN. If you do not have
one, you must apply for an SSN and give the
number to the county social services office within 60
days of your application.
Individuals are eligible for Medicare if they
are blind, disabled, have End Stage Renal
Disease, or are 64 years and 9 months of age
or older. You are responsible for telling your providers
that you have both Medi-Cal and Medicare coverage.
Apply for and enroll in any health insurance that
is available to you and your family at no cost.
Report to the county social services office
and the health care provider any health care coverage
or insurance that you have or are
entitled to use, including Medicare. If you
willfully do not give this information, you
may be billed by your provider and be guilty
of a crime.

• You can get help applying for an SSN from the

county social services worker.
You must work with the Social Security
Administration (SSA) to clear up any questions that
arise or your Medi-Cal will
be denied or stopped.

• If anyone on your application who otherwise

qualifies for Medi-Cal does not have a
satisfactory immigration status, he or she
can apply for restricted Medi-Cal benefits
without giving an SSN.

4. Apply for other income or benefits you or any family

member in your household are entitled
to, unless there is good cause for not applying.
This includes pensions, government benefits, retirement
income, veterans' benefits, annuities, disability benefits,
Social Security benefits
(Old Age, Survivors and Disability Insurance)
and unemployment benefits. This does not
include public assistance benefits such as CalWORKs
or CalFresh.

MC 219 (11/15) ENG5

0000000370843358
Page 26 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
You understand that:
1. You must use your other health care plan
(such as Kaiser, TRICARE or a Medicare
HMO) for medical care if you have other health insurance
that covers that service. Medi-Cal may not pay for any
services that are covered by other insurance.
2. If you dispute that you have other health
coverage, you can either: 1) contact your local county
social services worker; 2) call 1-800-541-5555; or, 3)
complete the other health coverage removal form on the
DHCS website
at http://dhcs.ca.gov/ohc.
3. If you, or any family member in your household, obtain
money from a legal settlement for injuries, including
medical expenses that Medi-Cal paid for, Medi-Cal is
entitled to be reimbursed from the medical expense
portion of the settlement.
4. If you do not make a choice about how you want to get
your benefits, you and family members in your household
may be placed in a Medi-Cal health plan near your home.
5. You must sign your Benefits Identification Cards (BICs)
and use it only to get necessary health care for yourself or
eligible family members.
6. You must take your BIC to your medical
provider when you are sick or have an
appointment. In emergencies when you do not have your
BIC, you must get the BIC to the medical provider as soon
as possible.
MC 219 (11/15) ENG6
DEPARTMENT OF HEALTH CARE SERVICES
7. You must tell DHCS at http://dhcs.ca.gov/pi when
Medi-Cal paid for medical services you received that
were the result of an accident
or injury caused by another person. This includes a
work place injury when a workers' compensation claim
may be filed.
8. You must cooperate with the State or county to
establish paternity and identify any possible medical
coverage that you or your family may be entitled to
through an absent parent, unless you are pregnant.
9. You must cooperate with the State if the quality control
review team chooses to review your case. If you refuse
to cooperate, your Medi-Cal benefits will be stopped.
10. If you don't apply for or keep no-cost health
coverage or state-paid coverage, your
Medi-Cal benefits and eligibility will be denied
or stopped.
11. If you do not give necessary information
or if you give information that you know
is false, your Medi-Cal benefits may be
denied or stopped. Your case may also be
investigated for suspected fraud.
12. The information you give when applying for Medi-Cal
will be checked by computer with facts given by
employers, banks, SSA, Internal Revenue Service,
Franchise Tax Board, social services and other
agencies.
This is to confirm income, citizenship, satisfactory
immigration status, tax information and other related
information to see if you and your family members in
your household qualify for health insurance. You
have the right to give proof to your county
social services worker and/or Covered
California to correct any wrong information.
0000000370843358
Page 27 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
13. Any changes in your information or the
information of any family member in your household
may affect the eligibility of other household members.
14. Only persons who are applying for Medi- Cal must give
their SSN and information about their immigration or
citizenship status. People who are not applying for
Medi-Cal are not required to give an SSN or proof of
immigration or citizenship status. You may choose to
give a non-applicant's SSN to help find if other family
members qualify.
15. Persons who do not have satisfactory immigration
status and who otherwise qualify for Medi-Cal can
apply for restricted Medi-Cal benefits without applying
for or giving an SSN.
16. Information about a person's immigration status given
on the Medi-Cal application is kept private and secure,
as required by law.
17. Based on your income, you may have to pay a
monthly premium for some Medi-Cal programs. For
other programs you may have to pay some of the cost
depending on your monthly income. If you have Medi-
Cal with a SOC, you may have to pay or promise to
pay for your medical expenses each month, up to
the amount of the SOC, before Medi-Cal will pay for
services.
18. If you do not report changes to your personal
information right away, and then receive Medi-Cal
benefits that you do not qualify for, you may have to
repay DHCS.
19. You, or any family member receiving Medi-Cal,
must not be getting public assistance from
another state.
MC 219 (11/15) ENG7
DEPARTMENT OF HEALTH CARE SERVICES
20. If you are receiving Medi-Cal based on disability and
you apply for disability benefits from SSA, and SSA
denies your disability claim, your
Medi-Cal may be stopped.
• If you appeal your SSA denial right away, you will
keep getting Medi-Cal until SSA makes a final
decision.
• If SSA approves your appeal, you will keep getting
Medi-Cal benefits.
• If SSA denies your appeal, then your Medi-Cal
benefits may stop.
21. As a condition of Medi-Cal eligibility, the State is
automatically assigned all rights to medical support
and payment for medical services for you and any
eligible persons you have legal responsibility for.
22. If medical support is court-ordered from an absent
parent for your children, the insurance carrier must
allow you to enroll and must provide benefits to your
children without the absent parent's consent.
23. Medi-Cal providers cannot collect private insurance
co-payment, co-insurance or deductibles from you
unless the payment is used to meet your Medi-Cal
SOC, co-payment or both.
24. When you apply for Medi-Cal you will be evaluated to
find out if you qualify for other medical assistance
programs, including the HIPP Program.
0000000370843358
Page 28 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
25. If you have other health insurance coverage, you may
only use Medi-Cal for services not covered by the other
health care plan. Your Medi-Cal provider must verify
that the service is not covered before billing Medi-Cal.
26. If you are admitted to a nursing facility and you do not
intend to return home, the State may put a lien against
your property.
27. After your death, the State must seek reimbursement
from your estate for all Medi-Cal services you received
after age 55 (including premiums paid on your behalf).
This does not apply during the lifetime of your surviving
spouse or registered domestic partner or if you are
survived by a child under age 21, or by a child of
any age who is blind or disabled (as defined by
the federal Social Security Act), or if the recovery
would create a hardship for your heirs. Please inform
your heirs of this potential collection activity.
MC 219 (11/15) ENG8
DEPARTMENT OF HEALTH CARE SERVICES
28. If you leave assets at the time of your death, when your
surviving spouse or registered domestic partner dies,
the State has the right to claim against your surviving
spouse's or registered domestic partner's estate or
against any recipient of those assets. Recovery is
limited to the amount of Medi-Cal benefits paid on your
behalf or the value of assets you own at the time of
death, whichever is less.
29. The State may seek reimbursement from your estate
for services you received (including premiums paid on
your behalf) prior to your 55th birthday if you were an
inpatient in a nursing facility, intermediate care facility
for the mentally retarded, or other medical institution.
For more information please contact your county
social services worker or go to DHCS's website at
http://dhcs.ca.gov/er.
KEEP THIS FOR YOUR RECORDS
0000000370843358
Page 29 of 37
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES

BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP)

The BCCTP may provide Medi-Cal to low-income people that live in California and have
breast and/or cervical cancer.

If you have been denied Medi-Cal or you are no longer eligible for Medi-Cal through your
county and you have breast and/or cervical cancer, tell your county Eligibility Worker (EW).
Your EW can make a referral for you to the BCCTP.

An Eligibility Specialist (ES) from the BCCTP will call or write to you for more information. The
requested information will help us to see if you are eligible for the program. You may be Medi-
Cal eligible through the BCCTP if you are a woman and you meet the following requirements:

• Have been screened and found in need of treatment for breast and/or cervical cancer,
follow-up care for cancer, or precancerous cervical lesions/conditions by an Every
Woman Counts (EWC) or Family Planning, Access, Care and Treatment (FamPACT)
provider; and
• Are a California resident; and
• Are under age 65; and
• Are a United States citizen or have satisfactory immigration status; and
• Have no other health insurance including full-scope no share-of-cost Medi-Cal, or
Medicare; and
• Have a monthly gross family income, at the time of screening and diagnosis, that is at
or below 200 percent of the federal poverty level.

If you have been screened for breast and/or cervical cancer by a provider that is not with EWC
or FamPACT, you can still be referred to the BCCTP. Your BCCTP worker will help you find
an EWC or FamPACT provider that can confirm your diagnosis.

Even if you do not meet all the above requirements, you may still receive BCCTP through the
State-funded BCCTP. The State-funded BCCTP can help you for up to 18 months for breast
cancer or up to 24 months for cervical cancer. The State-funded BCCTP is available to men
and women, regardless of immigration status.

For additional information or questions on the BCCTP, call 1-800-824-0088

MC Info Notice 372 (09/09)

0000000370843358
Page 30 of 37
 DISCRIMINATION COMPLAINTS
If you think you have been discriminated
against you may file a complaint. Where
you file your complaint depends on
PUB 13 (08/20)
which program your complaint is about.
For all programs your county agency
administers: Ask your county office for the
name, address and phone number of
their Civil Rights Coordinator. The county
will independently investigate your
complaint.
For Covered California:
Civil Rights Coordinator Covered California
PO Box 989725
West Sacramento, CA 95789
(916) 228-8764
CivilRights@covered.ca.gov
For Medi-Cal & Medi-Cal Dental Program:
You may contact the County’s Civil Rights
Coordinator, the state Dept. of Health Care
Services or the federal Health and Human
Services.
Department of Health Care Services,
Office of Civil Rights
P.O. Box 997413, MS 0009
Sacramento, CA 95899-7413
(916) 440-7370 or 711 (Calif. Relay Service)
CivilRights@dhcs.ca.gov
For all other state programs covered by
this pamphlet:
Civil Rights Unit
California Department of Social Services
P.O. Box 944243, M/S 8-16-70
Sacramento, CA 94244-2430
(866) 741-6241 (toll free)
0000000370843358
crb@dss.ca.gov
To file a CalFresh complaint with the
Federal agency:
United States Department of Agriculture
Director,
Office of Adjudication
1400 Independence Avenue, S.W.
Washington,
D.C. 20250-9410
(866) 632-9992 (toll free) or (202) 260-1026
(800) 877-8339 (hearing impaired)
program.intake@usda.gov
Page 31 of 37
To file a complaint with a federal agency:
Only for discrimination based on Race, Color,
National Origin, Disability, Age, or Sex:
Centralized Case Management Operation US YOUR
Dept. Health and Human Services
200 Independence Ave.,
S.W. Room 509F HHH Bldg.
Washington DC, 20201
File a complaint online at:
RIGHTS
US Health & Human Services Civil Rights
Complaint Portal
(800) 368-1019 (toll-free) UNDER CALIFORNIA PUBLIC
(800) 537-7697 (hearing/speech impaired) BENEFITS PROGRAMS
State of California
Time Limits for A Discrimination Complaint
Health & Human Services Agency
You must file a discrimination complaint Department of Social Services
within 180 days of the date you were
discriminated against.
This pamphlet is available from your local
If the discrimination also affected the level of County Welfare office and on the CDSS
your benefits and services, ask for a hearing.
website in the following languages:
A discrimination investigation cannot
change your benefit levels or services. • Arabic
Only a state hearing can do that. • Armenian
• Cambodian
You have 90 days from the date of the notice • Chinese
about your benefits to ask for a hearing. If • Farsi
you file after that time a judge will decide if • Hmong
you can have a hearing. • Japanese
• Korean
PROGRAMS COVERED BY THIS PAMPHLET
• Lao
• Adoption Assistance Program (AAP) • Mien
• Alcohol and Drug Program • Portuguese ….. for people applying for or receiving
• CA Food Assistance Program (CFAP) • Punjabi public aid in California
• CalWORKs • Russian
• Cash Assistance Program for Immigrants (CAPI) • Spanish
• CalFresh (Food Stamps) • Tagalog Tell us if you need help because of
• Ukranian a disability.
• Children’s Health Insurance Program (CHIP)
• Vietnamese
• Covered California Eligibility
• Foster Care/Child Welfare Services Also available for free in large print, Braille
• Housing Programs through County Social and audio CD. Ask for a free interpreter
Service Departments
This publication explains your rights, how to
• In-Home Supportive Services
ask for language assistance or a
• Kinship Guardianship Assistance (KinGAP) reasonable accommodation for a disability
• Medi-Cal – Medi-Cal Dental Program or impairment, and how to file a Public benefit agencies comply with
discrimination complaint. Federal and State law, and may not
• Refugee Cash Assistance
discriminate, exclude, or provide you aid,
• Resource Family Approvals (RFA) benefits or other services that is different
• Approved Relative Caregiver Funding Option from what is provided to others
Program (ARC)
• Service Animal Allowance PUB 13 (8/20)
 YOUR RIGHTS
All people and organizations providing
public assistance must respect your
rights. They can help you understand
and apply for benefits and services.
PUB 13 (08/20)
You have the right to an interpreter free
of charge.
• ‫اًﻧﺎﺟم ﯾروف ﻣﺟرﺗم ﯩﻠﻊ ﻟوﺻﺣﻼ ﻛل ﻗﺣﻲ‬
• Դղւք դւնեք թարգմանչի իրավունք ՝
անվճար
• អកនស ិ ិ ទទទួលអកបកែ្រប េយឥតគ
ិ ត
• ASKING FOR A STATE HEARING
有权免费获得口译员
• ‫ ﻣﺟرﺗم ﮐﯽ دﯾراد ﻗﺢ اﻣش‬، ‫دﯾﻧﮏ ﺗﻔﺎﯾرد ﻧﺎﮔﯾﺎر‬
• Koj muaj txoj cai kom tus neeg txhais
lus tsis raug them nqi
• request without an account
あなたには無料の通訳をもらう権利
があり ます
• 귀하는 통역사를 무료로 이용할 권리
가 있습니다
• Fax number:
ທ່ານມີສິດໄດ້ຮັບນາຍພາສາໂດຍບ�ເສຍຄ່າ
• mula sa nakasulat na ingles
hanggang sa nakasulat
• Sacramento, CA 94244-2430
Você tem direito a um intérprete,
gratuitamente
• If you have an urgent problem, you can ask for
• Вы имеете право на бесплатный
переводчик
• Tienes derecho a un intérprete, gratuito
May karapatan ka sa isang tagasalin,
•
nang walang bayad
• Ви маєте право на перекладача
безкоштовно
• Bạn có quyền phiên dịch, miễn phí
Ask the agency responsible for your benefits
0000000370843358
or services for language assistance.
YOU HAVE THE RIGHT TO:
1. Understand what is happening with
your application or benefits.
2. Get written and oral explanations about
your application or benefits. You have
a right to a free interpreter for this
information. Ask the agency responsible
for your benefits/services for language
assistance.
3. If the state agency has the written
explanation in non-English languages,
Page 32 of 37
you have a right to get this information
in those languages.
4. Get a receipt for documents you
hand-deliver.
5. See your case record
6. See laws and regulations about
your program.
7. Ask a judge to review any agency
action or inaction about your
eligibility, benefits, or services.
8. Not face discrimination in
applying for or receiving program
benefits or services.
9. File a complaint about discrimination.
10. Get a “reasonable accommodation” if
you have a disability or impairment.
This is special help for you to access or
participate in the program.
11. Have your information kept confidential.
12. Be treated with courtesy and respect.
IF YOU ARE HAVING PROBLEMS WITH
YOUR BENEFITS OR SERVICES:
Keep records of all your information,
documents, and contacts with the agency.
Get a receipt when you turn anything in.
Bring someone with you to a meeting
with the agency.
Complain. There are 4 ways to do this:
Informal: You can ask to speak to a
supervisor to talk about problems with a
worker or to go over the rules and the
proposed action on your benefits or
services.
State Hearing: Ask for a state hearing if
you disagree with an action or agency
inaction about your benefits or services.
You must ask for a hearing within 90
days of the date of agency’s notice about
the benefits or services. If you ask for a
hearing after 90 days, a judge will need
to see if you have a good reason for
asking late, like illness or a
disability.
Discrimination complaint: See
Discrimination Complaint section in this
pamphlet
Grievance: You can file a complaint with
the agency if it has a grievance procedure.
This does not protect your benefits in the
way that asking for a state hearing does.
STATE HEARINGS
You can also ask for a state hearing if the
agency is not giving you benefits or
services you think you should get. See
PUB 412 for State Hearing information.
If your problem is with General Assistance
or general relief, you must ask for a county
hearing.
If your problem is with Social Security
benefits, you must contact the Social Security
Administration.
Appeals Case Management System Online -
you can create an account to get all your
appeal information online, or submit an online
Phone: 1-800-743-8525
Email: SHDCSU@dss.ca.gov
833-281-0905
Mail: State Hearings Division
PO Box 944243, MS 21-37
EXPEDITED HEARINGS
an “expedited” hearing to have the hearing
held sooner. For Medi-Cal, this is when regular
hearing scheduling could seriously jeopardize
the enrollee’s life, physical or mental health.
PROHIBITED DISCRIMINATION
Under State law, agencies may not deny
benefits or services or provide you aid that is
different from aid provided to others based on:
Race, Color, Ancestry, National Origin
(including language), Ethnic Group
Identification, Age, Physical or Mental
Disability, Medical Condition, Religion,
Sex, Gender, Gender Identity or
Expression, Sexual Orientation, Marital
Status, Domestic Partnership, Political
Affiliation, Citizenship, Immigration Status,
and Genetic Information.
Federal laws also prohibit discrimination on
several, although not all, of the bases listed
above. Federal Law also prohibits:
Delaying or denying the placement of a child
for adoption or into foster care based on the
race,
color, or national origin of the adoptive or
foster parents, or the child;
Denying any individual the opportunity to
become a foster or adoptive parent based
on the race, color, or national origin of the
individual or child involved.
EXAMPLES OF DISCRIMINATION
The agency does not give you a free
interpreter.
A worker tells a certain ethnic group about
more programs and services than people
of other ethnicities.
The agency won’t help you get large print
or Braille versions of written information to
help you with visual impairment.
A worker learns of your religion or sexual
orientation and then treats you differently.
You can’t get to appointments because the
agency building does not have an elevator
and you have a disability limiting your use
of stairs.
You cannot get your wheelchair into
examination, interview rooms or restrooms.
The agency does not want you to have
training because they say you are “too old.”
REASONABLE ACCOMMODATIONS:
SPECIAL HELP FOR PEOPLE WITH
DISABILITIES
A person with a physical or mental
disability may have the right to a free
reasonable accommodation from a
government agency to help them access
and participate in programs and services. If
you have a disability and need extra help,
you should ask the local or state agency
responsible for your application or benefits/
services. The agency must work with you
to determine what help you need. If the
agency is denying you an accommodation,
it must give you written notice stating the
reason for the denial. The notice must list
your appeal rights.
 What Does CHDP Offer? Information English

PUB 183 (9/15)

The CHDP program helps to prevent or find
health problems through regular, no cost,
health check-ups. A check-up includes:
• Health and developmental history
• Physical exam
• Needed shots
• Oral health screening and routine
referral to a dentist starting by age 1
• Nutrition screening
• Behavioral screening
• Vision screening
• Hearing screening
• Health information
• Lab tests, which may include:
anemia, lead, tuberculosis, and other
problems, as needed
• Referral to Women, Infants,
and Children (WIC) program for
children up to age 5
Other Services
For more information about CHDP,
transportation options, or for help setting
up an appointment, contact your local
CHDP office. Child Health and Disability
You can find your local CHDP office by Prevention (CHDP) Program
visiting the California Department of
Health Care Services website at:
www.dhcs.ca.gov/services/chdp
Medical and Dental
Health Check-Ups
Regular health check-ups keep your child
healthy.
Health check-ups can also
find and treat problems before they
become serious.

If further health services are needed, we

will help you find them, including:

0000000370843358
• Dentists that accept Denti-
Cal for the care of your
child’s teeth
• Medical specialists, as
needed FREE
Edmund G. Brown, Jr.
• Mental and behavioral Governor, State of California
health services, as needed For Babies, Children, and Youth
Under age 21 with Full Scope Medi-Cal or
Diagnosis and treatment can be paid for as
Under Age 19 with Low Family Income.
long as your child has Medi-Cal. PUB 183 (English, 9/15)
No Documentation Required

Page 33 of 37
 Why Get Health Check-Ups?
PUB 183 (9/15)
Health check-ups are important for all children and youth. Health check-ups are a time to:
• Find and address medical, dental, mental, and behavioral health problems
• Get needed shots
• Ask your doctor questions
Health check-ups can also be used for foster care, sports, camp, or school entry, as
needed.
Babies and Toddlers
Birth Through 3 Years
Regular check-ups can keep your baby
happy and healthy. You can find out about
your baby’s growth,weight, and health, and
needed shots are given. At 1 year and 2
years, your baby should be tested for lead.
A test for anemia is also given. Your child
should see a dentist at least once a year
starting by age 1.
0000000370843358
Dental
Please contact your local CHDP office for
assistance to find a Dentist who accepts
Denti-Cal. CHDP may also assist with
appointment scheduling and transportation
if necessary.
Page 34 of 37
School Children
4 Through 12 Years
It is important to make sure your child is
healthy and ready for school. State laws
require children to be up to date on their
shots and get a health check-up.
School children will also get vision and
hearing screenings. If your child has not
had a lead test before, he/she should
have one by age 6 or before. Your child
should see a dentist at least once a year.
Vision & Hearing
The local CHDP office can provide
assistance to obtain vision and hearing
services if medically necessary.
Who is Eligible?
Children and youth up to age 21 who are
eligible for Medi-Cal. Children and youth
under age 19 with family incomes less than
or equal to 200% Federal Income
Guidelines are also eligible. Proof of
residence and income is not required.
Teens and Young Adults
13 Through 20 Years
Teens need health check-ups too! This is a
chance to make sure your teen is growing
and developing well. It is also a time for
you or your teen to ask the doctor any
questions. Extra health check-ups can be
given for sports and camp physicals. Your
child should see a dentist at least once a
year.
Mental Health, Autism
and Behavioral Services
Contact the local CHDP office for
assistance to access these services.
 Medi-Cal Services
for Children and
Young Adults:
Early & Periodic Screening,
Diagnosis & Treatment
Mental Health Services
This notice is for children and young
adults (under age 21) who qualify for
Medi-Cal EPSDT services and their
caregivers or guardians
What are EPSDT Services?
EPSDT mental health services are Medi-Cal
services that correct or improve mental health
problems that your doctor or other health care
provider finds, even if the health problem will not
go away entirely. EPSDT mental health services
are provided by county mental health departments.
These problems may include sadness, nervousness,
or anger that makes your life difficult.
You must be under age 21 and have full
scope Medi-Cal to get these services.
How to get EPSDT Services for yourself
(under age 21) or your child
Ask your doctor or clinic about EPSDT services. You
or your child may receive these services if you and
your doctor, or other health care provider, clinic
(such as the Child Health and Disability Prevention
Program), or county mental health department
agree that you or your child need them. You may
also call your local county mental health
department directly. The call is free.
MC 003 (11/12)
Types of EPSDT Services
Some of the services you can get from your county
mental health department are:
• Individual therapy
• Group therapy
• Family therapy
• Crisis counseling
• Case management
• Special day programs
• Medication for your mental health
Counseling and therapy services may be provided in
your home, in the community, or in another location.
Your county mental health department, and your
doctor or provider will decide if the services you ask
for are medically necessary.
County mental health departments
must approve your EPSDT services.
Every county mental health department has a tollfree
phone number that you can call for more information
and to ask for EPSDT mental health services.
What are EPSDT
Therapeutic Behavioral Services?
Therapeutic Behavioral Services (TBS) are an EPSDT
specialty mental health service. TBS helps children
and young adults who:
• Have severe emotional problems;
• Live in a mental health placement or are at risk of
placement; or
• Have been hospitalized recently for mental health
problems or are at risk for psychiatric
hospitalization.
If you get other mental health services and still feel
very sad, nervous, or angry, you may be able to have
a trained mental health coach help you. This person
could help you when you have problems that might
cause you to get mad, upset, or sad. This person
would come to your home, group home or go with you
on trips and activities in the community.
0000000370843358
Page 35 of 37
Your county mental health department can tell
you how to ask for an assessment to see if you
need mental health services including TBS.
Who can I talk to about EPSDT mental
health services?
Your doctor, psychologist, counselor, social
worker, or other health or social services provider
can assist you with finding EPSDT mental health
services. For children and young adults in a group
home or residential facility, talk to the staff about
getting additional EPSDT services.
For children in foster care, consult the child’s
court-appointed attorney. You can also call your
county mental health department directly. (Look in your
phone book for the toll-free telephone number, or call
the Department of Health Care Services Mental Health
Ombudsman’s Office).
What if I don’t get the services I want
from my county mental health
department?
You can file an appeal with your county mental
health department if they deny the EPSDT services
requested by your doctor or provider. You may also
file an appeal if you think you need mental health
services and your provider or county mental health
department does not agree.
Call the county mental health department’s toll-free
number to talk to a Problem Resolution (grievance/
appeal) coordinator for information and help. You
may also call the county patients’ rights advocate,
or the Department of Health Care Services, Mental
Health Ombudsman Office.
MC 003 (11/12)
You can ask for a state hearing within 90 days after
exhausting the county mental health department’s
appeal process by doing one of the following:
• Call: 1-800-952-5253, or
for TTY 1-800-952-8349;
• Fax: 916-651-5210; or 916-651-2789
• Write: California Department of Social Services,
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430.
Where can I get more information?
For more information please contact the following
offices at the telephone numbers below.
County Mental Health Department
toll–free access number
Look in your local phone book
Department of Health Care Services
Mental Health Ombudsman’s Office
1-800-896-4042
Department of Health Care Services website
www.dhcs.ca.gov
For additional information about mental
health and EPSDT, please go to the following
webpages:
www.dhcs.ca.gov/services/mh
www.dhcs.ca.gov/services/mh/pages/EPSDT.aspx
0000000370843358
Page 36 of 37
 If you are not registered to vote where you live now, would you like to apply to register to vote here today?
(Check One)

Already registered. I am registered to vote at my current residence address.

Yes. I would like to register to vote. (Please fill out the attached voter registration form.)

No. I do not want to register to vote.

NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED
NOT TO REGISTER TO VOTE AT THIS TIME. YOU MAY TAKE THE ATTACHED VOTER
REGISTRATION FORM TO REGISTER AT YOUR CONVENIENCE.

Applicant Name Date

Important Notices

1. Applying to register or declining to register to vote will not affect the amount of assistance that you will be
provided by this agency.

2. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or
accept help is yours. You may fill out the voter registration form in private.

3. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to
privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political
party preference or other political preference, you may file a complaint with the Secretary of State by calling toll-
free (800) 345-VOTE (8683) or you may write to: Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814.
For more information on elections and voting, please visit the Secretary of State's website at www.sos.ca.gov.

NVRA VPF (01/13) Voter Preference Form

0000000370843358
Page 37 of 37