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A ADDITIONAL CHILDREN (SUPPLEMENT TO THE MEDI-CAL STATEMENT (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services

ADDITIONAL CHILDREN

(SUPPLEMENT TO THE MEDI-CAL STATEMENT OF FACTS—MC 210)

IF YOU HAVE MORE THAN THREE CHILDREN, LIST HERE AND GIVE THIS FORM TO YOUR WORKER.

COUNTY USE ONLY

Case name:

Case number:

Worker number:

Date:

____________________________

______________________________________

__________________________

_________________________

_________________________________

Child’s name (first, middle, last) or “unborn” Relationship to applicant

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Social Security number In school

! Yes ! No

Sex

! Male ! Female

Birthdate or date unborn is due Is the person blind or disabled

! Yes ! No

Pregnant

! Yes ! No

Father’s name Is either parent (")

! Deceased ! Incapacitated ! Absent ! Unemployed

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Mother’s name Child living in home

! Yes ! No

Medi-Cal requested

! Yes ! No

Child’s name (first, middle, last) or “unborn” Relationship to applicant

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Social Security number In school

! Yes ! No

Sex

! Male ! Female

Birthdate or date unborn is due Is the person blind or disabled

! Yes ! No

Pregnant

! Yes ! No

Father’s name Is either parent (")

! Deceased ! Incapacitated ! Absent ! Unemployed

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Mother’s name Child living in home

! Yes ! No

Medi-Cal requested

! Yes ! No

Child’s name (first, middle, last) or “unborn” Relationship to applicant

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Social Security number In school

! Yes ! No

Sex

! Male ! Female

Birthdate or date unborn is due Is the person blind or disabled

! Yes ! No

Pregnant

! Yes ! No

Father’s name Is either parent (")

! Deceased ! Incapacitated ! Absent ! Unemployed

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Mother’s name Child living in home

! Yes ! No

Medi-Cal requested

! Yes ! No

Child’s name (first, middle, last) or “unborn” Relationship to applicant

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Social Security number In school

! Yes ! No

Sex

! Male ! Female

Birthdate or date unborn is due Is the person blind or disabled

! Yes ! No

Pregnant

! Yes ! No

Father’s name Is either parent (")

! Deceased ! Incapacitated ! Absent ! Unemployed

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Mother’s name Child living in home

! Yes ! No

Medi-Cal requested

! Yes ! No

Child’s name (first, middle, last) or “unborn” Relationship to applicant

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Social Security number In school

! Yes ! No

Sex

! Male ! Female

Birthdate or date unborn is due Is the person blind or disabled

! Yes ! No

Pregnant

! Yes ! No

Father’s name Is either parent (")

! Deceased ! Incapacitated ! Absent ! Unemployed

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Mother’s name Child living in home

! Yes ! No

Medi-Cal requested

! Yes ! No

Child’s name (first, middle, last) or “unborn” Relationship to applicant

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Social Security number In school

! Yes ! No

Sex

! Male ! Female

Birthdate or date unborn is due Is the person blind or disabled

! Yes ! No

Pregnant

! Yes ! No

Father’s name Is either parent (")

! Deceased ! Incapacitated ! Absent ! Unemployed

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Mother’s name Child living in home

! Yes ! No

Medi-Cal requested

! Yes ! No

MC 210 S-C (ENG/SP) (05/07)

! ! ! !

! ! !

! ! ! !

! ! !

! ! ! !

! ! !

! ! ! !

! ! !

! ! ! !

! ! !

! ! ! !

! ! !

! ! ! !

State of California—Health and Human Services Agency Department of Health Care Services

NIÑOS ADICIONALES

(SUPLEMENTO A LA DECLARACION DE DATOS DE MEDI-CAL—MC 210)

SI TIENE MAS DE TRES NIÑOS, ANOTELOS AQUI Y DELE ESTA FORMA A SU TRABAJADOR(A)

PARA USO DEL CONDADO

Case name:

Case number:__________________________

Worker number: ________________________

Date:_________________________________

___________________________

_____________________________________

Nombre del niño (nombre, inicial, apellido) o “por nacer” Parentesco con el solicitante

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Número del Seguro Social ¿Asiste a la escuela?

! Sí ! No

Sexo

! Masc. ! Fem.

Fecha de nacimiento o fecha en que se espera nacerá el bebé ¿Está la persona ciega o inca-

pacitada? ! Sí ! No

¿Embarazada?

! Sí ! No

Nombre del padre ¿Está cualquiera de los padres (")

Muerto ! Incapacitado ! Ausente ! Desempleado

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Nombre de la madre ¿Vive el niño en el hogar?

! Sí ! No

¿Solicitó Medi-Cal?

! Sí ! No

Nombre del niño (nombre, inicial, apellido) o “por nacer” Parentesco con el solicitante

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Número del Seguro Social ¿Asiste a la escuela?

! Sí ! No

Sexo

! Masc. ! Fem.

Fecha de nacimiento o fecha en que se espera nacerá el bebé ¿Está la persona ciega o inca-

pacitada? ! Sí ! No

¿Embarazada?

! Sí ! No

Nombre del padre ¿Está cualquiera de los padres (")

Muerto ! Incapacitado ! Ausente ! Desempleado

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Nombre de la madre ¿Vive el niño en el hogar?

! Sí ! No

¿Solicitó Medi-Cal?

! Sí ! No

Nombre del niño (nombre, inicial, apellido) o “por nacer” Parentesco con el solicitante

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Número del Seguro Social ¿Asiste a la escuela?

! Sí ! No

Sexo

! Masc. ! Fem.

Fecha de nacimiento o fecha en que se espera nacerá el bebé ¿Está la persona ciega o inca-

pacitada? ! Sí ! No

¿Embarazada?

! Sí ! No

Nombre del padre ¿Está cualquiera de los padres (")

Muerto ! Incapacitado ! Ausente ! Desempleado

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Nombre de la madre ¿Vive el niño en el hogar?

! Sí ! No

¿Solicitó Medi-Cal?

! Sí ! No

Nombre del niño (nombre, inicial, apellido) o “por nacer” Parentesco con el solicitante

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Número del Seguro Social ¿Asiste a la escuela?

! Sí ! No

Sexo

! Masc. ! Fem.

Fecha de nacimiento o fecha en que se espera nacerá el bebé ¿Está la persona ciega o inca-

pacitada? ! Sí ! No

¿Embarazada?

! Sí ! No

Nombre del padre ¿Está cualquiera de los padres (")

Muerto ! Incapacitado ! Ausente ! Desempleado

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Nombre de la madre ¿Vive el niño en el hogar?

! Sí ! No

¿Solicitó Medi-Cal?

! Sí ! No

Nombre del niño (nombre, inicial, apellido) o “por nacer” Parentesco con el solicitante

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Número del Seguro Social ¿Asiste a la escuela?

! Sí ! No

Sexo

! Masc. ! Fem.

Fecha de nacimiento o fecha en que se espera nacerá el bebé ¿Está la persona ciega o inca-

pacitada? ! Sí ! No

¿Embarazada?

! Sí ! No

Nombre del padre ¿Está cualquiera de los padres (")

Muerto ! Incapacitado ! Ausente ! Desempleado

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Nombre de la madre ¿Vive el niño en el hogar?

! Sí ! No

¿Solicitó Medi-Cal?

! Sí ! No

Nombre del niño (nombre, inicial, apellido) o “por nacer” Parentesco con el solicitante

Linkage

Citizen/

Immig.

MC 13

SSN Preg ID

Número del Seguro Social ¿Asiste a la escuela?

! Sí ! No

Sexo

! Masc. ! Fem.

Fecha de nacimiento o fecha en que se espera nacerá el bebé ¿Está la persona ciega o inca-

pacitada? ! Sí ! No

¿Embarazada?

! Sí ! No

Nombre del padre ¿Está cualquiera de los padres (")

Muerto

Incapacitado

Ausente

Desempleado

Medical Support

YES

CA 2.1

Not in home, 18–21 and tax dep.?

Nombre de la madre ¿Vive el niño en el hogar?

! Sí ! No

¿Solicitó Medi-Cal?

! Sí ! No

MC 210 S-C (ENG/SP) (05/07)

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A ADDITIONAL CHILDREN (SUPPLEMENT TO THE MEDI-CAL STATEMENT (Department of Health Care Services)

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Completed 30 July 2020

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