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A APPLICANTS SUPPLEMENTAL STATEMENT OF FACTS FOR MEDI-CAL (Department of Health Care Services)

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A
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_____________________________________________________________________________________________
_____________________________________________________________________________________________
State of California—Health and Human Services Agency Department of Health Care Services
APPLICANT’S SUPPLEMENTAL STATEMENT
OF FACTS FOR MEDI-CAL
PART I—PERSONAL INFORMATION
COUNTY USE ONLY
County Number/Aid Code/Case Number
— —
1a. Applicant name (Last, First, MI) 1b. Social Security number
— —
1c. Date of birth
/ /
1d. Other name(s) used (Last, First, MI) 1e. Sex
❑
Male
❑
Female
1f. Height
Feet _______
Inches _____
1g. Weight
Pounds _________
2a. Home address City State ZIP code
2b. Mailing address (if different) City State ZIP code
3. Daytime telephone number Check if: Best time to call
❑
No Phone
(
)
❑
Message Phone ( )
4a. Do you speak English? 4b. Do you have an If YES, interpreter’s name: Best time to call
interpreter?
❑ Yes If YES, go to Part II
❑
Yes
❑
No
Interpreter’s phone number:
❑
No If NO, what language(s) do you speak:
( )
COUNTY USE ONLY
PART II—MEDICAL INFORMATION
5. Have you applied for Social Security Disability or Supplemental Security Income (SSI) Disability
benefits in the past two (2) years?
❑ Yes ❑ No
If YES, please answer the following:
a. Was/Is your Social Security or SSI Disability application:
❑ Approved? ❑ Denied? ❑ Pending? ❑ On Appeal? ❑ Unknown?
b. If approved or denied, give the date of the most recent decision on your Social Security or SSI disability
application: _________________________________________________________________________________
c. Has your medical problem(s) worsened since the date in 5b above?
❑ Yes ❑ No
If YES, please explain: ______________________________________________________________________
d. Do you have any NEW medical problem(s) since the date in 5b, above, which you did NOT have when
your Social Security or SSI disability decision was made?
❑ Yes ❑ No If YES, what medical problem(s)? _________________________________________
6. List all medical problems (physical, mental or emotional) that keep you from working or taking care of your personal needs.
(Please attach additional sheet, if necessary.)
WHEN DID IT
MEDICAL PROBLEM(S)
START (Month/Year)
Page 1 of 8
MC 223 (05/07)
Page 1 of 8
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_____________________________________________________________________________________________________
__________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________
COUNTY USE ONLY
7. Have you received care in a clinic or hospital for your illness(es) or injury(ies) in the last
12 months?
❑
Yes
❑
No
If YES, please fully answer the following:
Name of clinic/hospital
Patient/clinic or member number Clinic/hospital telephone number
( )
Name of doctor(s) seen
ADDRESS of clinic/hospital (number, street, suite) City State ZIP code
Date first seen Date last seen Date of next appointment
Reason for the visit(s)
Did you stay in the hospital overnight?
❑
Yes
❑
No
If YES, date(s) entered: _______________________________
date(s) left: ______________________________
Were you seen in the emergency room?
❑
Yes
❑
No
If YES, date(s) seen: _______________________________________________________________________________
List ALL medicines received:
______________________________________________________________________
List ALL treatments received and the dates the treatments were received: _____________________
8. List any additional clinic or hospital where you have been seen in the last 12 months.
Name of clinic/hospital
Patient/clinic or member number Clinic/hospital telephone number
( )
Name of doctor(s) seen
ADDRESS of clinic/hospital (number, street, suite) City State ZIP code
Date first seen Date last seen Date of next appointment
Reason for the visit(s)
Did you stay in the hospital overnight?
❑
Yes
❑
No
If YES, date(s) entered:
_______________________________ date(s) left: ________________________________
Were you seen in the emergency room?
❑
Yes
❑
No
If YES, date(s) seen: _______________________________________________________________________________
List ALL medicines received: ______________________________________________________________________
List ALL treatments received and the dates the treatments were received: ________________________
If you have been seen at additional clinics or hospitals
in the last 12 months, complete page 8.
MC 220 Signed
❑
MC 220 Signed
❑
MC 223 (05/07)
Page 2 of 8
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______________________________________________________________________________________________________
______________________________________________________________________________________________________
9. Have you been seen by any doctor outside of the clinic(s) or hospital(s) you have already
COUNTY USE ONLY
listed in the last 12 months? ❑ Yes ❑ No
If NO, go to number 10. If YES, please fully answer the following, if more than one doctor was seen
please complete page 8 for all additional information:
Name of doctor(s)
Patient/clinic or member number Doctor’s telephone number
( )
Address of doctor (number, street, suite) City State ZIP code
MC 220 Signed
❑
Date first seen Date last seen Date of next appointment
Reason for the visit(s)
List ALL medicines received: ______________________________________________________________________
List ALL treatments received and the dates the treatments were received: ________________________
10.
Please list below if you have had any of the following tests in the last 12 months. Be sure to check
yes or no next to each test. (IF ADDRESS OF DOCTOR, CLINIC, OR HOSPITAL WAS GIVEN
ALREADY, LIST ONLY THE NAME AND DATE.)
TEST NAME AND ADDRESS OF OFFICE, CLINIC, DATE
PERFORMED YES NO OR HOSPITAL WHERE TEST WAS COMPLETED (MO/YR)
Name
MC 220 Signed
Electrocardiogram
Address (number, street, suite)
(EKG)
❑
City State ZIP Code
Name
MC 220 Signed
Treadmill Address (number, street, suite)
❑
(exercise heart test)
City State ZIP Code
Name
MC 220 Signed
Chest X-ray Address (number, street, suite)
❑
City State ZIP Code
Name
MC 220 Signed
Breathing Test Address (number, street, suite)
❑
(PFT)
City State ZIP Code
Name
MC 220 Signed
Blood Tests Address (number, street, suite)
❑
City State ZIP Code
Name
MC 220 Signed
(Specify)
Other Address (number, street, suite)
❑
City State ZIP Code
MC 223 (05/07)
Page 3 of 8
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__________________________________________________________________________________________
__________________________________________________________________________________________
11.
Have you had any other medical treatment or testing in the past 12 months? ❑ Yes ❑ No
COUNTY USE ONLY
If NO, go to number 12.
If YES, complete page 8.
12.
Is there anyone else (a friend, relative, social worker, rehab counselor, attorney, physical therapist,
etc.) we may contact for information regarding your illness or injury and how it limits your daily
activities or keeps you from working?
❑
Yes
❑
No
If YES, please list below:
Name
Address (number, street, suite)
Telephone number
( )
Name
Relationship to you
Address (number, street, suite)
Telephone number
( )
Name
Relationship to you
Address (number, street, suite)
Telephone number
( )
Relationship to you
13.
You may be asked to go to additional medical examinations to help evaluate your medical
problem(s). (These examinations are free to you.)
Are you willing to go to additional medical examinations if needed? ❑ Yes ❑ No
PART III—SOCIAL AND EDUCATIONAL INFORMATION
14.
Describe your daily activities and tell us how much your condition limits your activities.
15.
Describe your educational background.
a. Check the highest grade you finished in school:
❑ 1 ❑ 2 ❑ 3 ❑ 4 ❑ 5 ❑ 6 ❑ 7 ❑ 8 ❑ 9 ❑ 10 ❑ 11
❑ 12 or ❑ GED (same as finishing 12th grade) ❑ 12+
b. When finished? Month/year: ________________________________
c. Did you take special education classes?
❑ Yes ❑ No
16.
Have you done any type of work for more than 30 days during the last 15 years? (This includes
work done in another country.)
❑ Yes ❑ No
If NO, skip Part IV, go to Part V, page 7, for your signature.
If YES, answer Part IV, page 5, beginning with number 17.
MC 223 (05/07)
Page 4 of 8
PART IV—WORK HISTORY
COUNTY USE ONLY
17. Describe all of the jobs you have done for at least 30 days during the last 15 years. Start with your most
recent job. (If you had more than two jobs, ask your county worker for additional pages.)
a. Job title Type of business
Dates worked (month/year) Hours per week Rate of pay Per hour/wk/mo
From: To:
DESCRIPTION OF THE JOB (This is what I did and how I did it.)
These are the tools, machines, and equipment I used:
I took this long to learn the job: _______________ day(s) or _______________ month(s).
I wrote, completed reports, or performed similar duties: ❑ Yes ❑ No
I had supervisory responsibilities: ❑ Yes ❑ No
PHYSICAL ACTIVITY Circle One
I walked this many hours in an average workday: 012345678
I stood this many hours in an average workday: 012345678
I sat this many hours in an average workday: 012345678
I climbed this much in an average workday:
❑
Never
❑
Occasionally
❑
Frequently
❑
Constantly
I bent over this much in an average workday:
❑
Never
❑
Occasionally
❑
Frequently
❑
Constantly
Heaviest weight I lifted:
❑
10 lbs
❑
20 lbs
❑
50 lbs
❑
Over 100 lbs
I often lifted/carried up to:
❑
10 lbs
❑
20 lbs
❑
50 lbs
❑
Over 100 lbs
Did you have any of your current medical problem(s) when you performed this
job?
❑
Yes
❑
No
If NO, and you have had NO other jobs go to Part V, page 7, for your signature. If NO, but you
have had other jobs, go to 17b, next page. If YES, please complete the following information.
Name of medical problem(s): ___________________________________________________________
Did your employer make special arrangements (such as extra breaks, special equipment, change
in job duties, etc.) so you could continue to work?
❑
Yes
❑
No
If YES, describe the special arrangements made: ________________________________________
Did you have to stop working because of your medical problem(s)? ❑ Yes ❑ No
If YES, when? Month ____________________________________ Day _________ Year _________
Have you done any other work for more than 30 days during the last 15 years? ❑ Yes ❑ No
If NO, go to Part V, page 7 for your signature. If YES, continue on 17b, next page.
MC 223 (05/07)
Page 5 of 8
COUNTY USE ONLY
17.
b. Job title Type of business
Dates worked (month/year) Hours per week Rate of pay Per hour/wk/mo
From: To:
DESCRIPTION OF THE JOB (This is what I did and how I did it.)
These are the tools, machines, and equipment I used:
I took this long to learn the job: _______________ day(s) or _______________ month(s).
I wrote, completed reports, or performed similar duties: ❑ Yes ❑ No
I had supervisory responsibilities: ❑ Yes ❑ No
PHYSICAL ACTIVITY Circle One
I walked this many hours in an average workday: 012345678
I stood this many hours in an average workday: 012345678
I sat this many hours in an average workday: 012345678
I climbed this much in an average workday:
❑
Never
❑
Occasionally
❑
Frequently
❑
Constantly
I bent over this much in an average workday:
❑
Never
❑
Occasionally
❑
Frequently
❑
Constantly
Heaviest weight I lifted:
❑
10 lbs
❑
20 lbs
❑
50 lbs
❑
Over 100 lbs
I often lifted/carried up to:
❑
10 lbs
❑
20 lbs
❑
50 lbs
❑
Over 100 lbs
Did you have any of your current medical problem(s) when you performed this
job?
❑
Yes
❑
No
If NO, and you have had NO other jobs go to Part V, page 7, for your signature. If NO, but you
have had other jobs, ask your county worker for additional pages. If YES, please complete the
following information.
Name of medical problem(s): ___________________________________________________________
Did your employer make special arrangements (such as extra breaks, special equipment, change
in job duties, etc.) so you could continue to work?
❑
Yes
❑
No
If YES, describe the special arrangements made: ________________________________________
Did you have to stop working because of your medical problem(s)?
❑ Yes ❑ No
If YES, when? Month ____________________________________ Day _________ Year ________
Have you done any other work for more than 30 days during the last 15 years? ❑ Yes ❑ No
If NO, go to Part V, page 7 for your signature. If YES, ask your county worker for additional
pages to complete.
MC 223 (05/07)
Page 6 of 8
PART V—SIGNATURE AND CERTIFICATION
I declare under penalty of perjury under the laws of the United States of America and the State of California that the
information contained in this Supplemental Statement of Facts is true and correct.
Signature of Applicant Date
➧
Signature of Witness (If applicant signed with a mark) Date
➧
Signature of person helping applicant fill out the form Date
➧
You will need to sign an authorization for release of information for
each clinic, hospital, and testing facility that you list and for each
doctor you saw outside of a clinic or hospital. Your county worker will
provide you with additional forms which you will need to sign.
MC 223 (05/07)
Page 7 of 8
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______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
Continued answer(s) to question(s) number 8 on page 2, number 9 on page 3, and number 10 on page
COUNTY USE ONLY
3. If you need more room, please ask your county worker for additional pages to complete.
List any additional clinic or hospital where you have been seen in the last 12 months:
Name of clinic/hospital
Patient/clinic or member number Clinic/hospital telephone number
( )
Name of doctor(s) seen
ADDRESS of clinic/hospital (number, street, suite) City State ZIP code
MC 220 Signed
❑
Date first seen Date last seen Date of next appointment
Reason for the visit(s)
Did you stay in the hospital overnight?
❑
Yes
❑
No
If YES, date(s) entered: ______________________________ date(s) left: __________________________________
Were you seen in the emergency room? ❑ Yes ❑ No
If YES, date(s) seen: ________________________________________________________________________
List ALL medicines received:
_______________________________________________________________________
List ALL treatments received and the dates the treatments were received:
________________________
List any additional doctor you saw outside of the clinic(s) or hospital(s) you have already listed:
Name of doctor(s)
Patient/clinic or member number Doctor’s telephone number
( )
Name of doctor(s) seen
ADDRESS of doctor (number, street, suite) City State ZIP code
Date first seen Date last seen Date of next appointment
Reason for the visit(s)
MC 220 Signed
❑
List ALL medicines received: ________________________________________________________________
List ALL treatments received and the dates the treatments were received: ________________________
List any additional tests you have had in the last 12 months:
NAME AND ADDRESS OF OFFICE, CLINIC, OR HOSPITAL DATE
TEST PERFORMED WHERE TEST(S) WAS COMPLETED. (MO/YR)
Name
Address (number, street, suite)
City State ZIP code
Name
MC 220 Signed
❑
Address (number, street, suite)
MC 220 Signed
City State ZIP code
❑
MC 223 (05/07)
Page 8 of 8
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A APPLICANTS SUPPLEMENTAL STATEMENT OF FACTS FOR MEDI-CAL (Department of Health Care Services)

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