Fillable APPLICATION AND STATEMENT OF FACTS FOR CHILD NOT (Department of Health Care Services)

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APPLICATION AND STATEMENT OF FACTS FOR CHILD NOT (Department of Health Care Services)

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APPLICATION AND STATEMENT OF FACTS
FOR CHILD NOT LIVING WITH A PARENT OR RELATIVE
AND FOR WHOM A PUBLIC AGENCY IS
ASSUMING SOME FINANCIAL RESPONSIBILITY
❒ New application ❒ Redetermination ❒ Request retroactive coverage for ________ months
Name of child Sex Birth date (mm/dd/yy) Birth place
❒ Male ❒ Female
Social Security number Social Security claim number U.S. citizen
❒ Yes ❒ MC 13 attached (required)
❒ No ❒ Alien registration number ________________________
Mother’s name Mother’s Social Security number (if known) Father’s name Father’s Social Security number (if known)
Name of person or institution with whom placed
Address (number, street) City State ZIP code
Mailing address (number, street, P.O. Box) (if different) City State ZIP code
Child is detained under Welfare and Institutions Code, Title IV-E eligible? ❒ Yes ❒ No
Section 602
❒ Yes ❒ No Date adoption agreement terminates or renews________________
Monthly amount paid from public funds for child’s care Date of present placement or move to California (children placed by
which is not reimbursed by the child’s parents. $____________ another state) ________________
Medical insurance ❒ Yes ❒ No
If yes, insurance company ___________________________________ SSI/SSP application made?
❒ Yes ❒ No
Child’s Ethnic Group (check one box only) Child’s Language (check one box only) (If he/she can speak and
understand English, check English)
❒ White (not of Hispanic origin) ❒ Hispanic ❒ English ❒ Korean
❒ American Indian or Alaskan Native ❒ Filipino ❒ Spanish ❒ Vietnamese
❒ Black (not of Hispanic origin) ❒ Chinese ❒ Filipino (Tagalog)
❒ Asian or Pacific Islander ❒ Japanese ❒ Other (specify) ____________________
Signature of public agency representative (or attach Cert Letter) Date Telephone number
➤ ( )
Name of responsible public agency Contact person Telephone number
( )
Street address (number, street) City State ZIP code
SEE REVERSE SIDE FOR INSTRUCTIONS
State of California—Health and Human Services Agency Department of Health Care Services
MC 250 (05/07)
COUNTY USE ONLY
Case name:
Case number:
Effective date:
MC 250 (05/07)
INSTRUCTIONS FOR USE OF FORM MC 250 AS AN APPLICATION
Public Agency Representative
Form MC 250 is to be completed by you when requesting Medi-Cal coverage for a child who is not living with a parent or relative
and for whom you are accepting financial responsibility in whole or in part. You are accepting financial responsibility if you have
responsibility for the child’s placement and you pay for part or all of the child’s care with your agency’s funds. If you represent
a Title IV–E adoptions assistance or foster care child placed by your state, who is now living in California, you must also provide
a letter (Cert Letter) certifying the child’s federal eligibility and entitlement to Medicaid benefits.
A Social Security number must be provided for the child if the child is a U.S. citizen or if he/she has satisfactory immigration
status (SIS). If the child does not have a number and is required to have one, you must apply for one for him/her in order for
the child to remain eligible for Medi-Cal. If you have made an application for a Social Security number, write “app. on (the
appropriate month, day, and year)” under Social Security number. Notify the county welfare department as soon as you receive
the number.
If SIS is claimed for the child, he/she is presumptively eligible for full scope Medi-Cal in accordance with instructions in
ACWDL 92-48. SIS includes aliens who are lawful permanent residents, Permanently Residing in the United States Under Color
of Law (PRUCOL), or amnesty aliens with a valid and current I-688.
The completed MC 250 is to be mailed to the county welfare department (CWD) which is located in the same county as your
agency. Each section of the form must be complete and the information provided must be true and correct to the best of your
knowledge. You are also responsible for reporting immediately to the CWD any change in the circumstances of the child which
may affect the child’s eligibility.
Adoptive/Foster Parents of Title IV–E Children Placed by Another State
You may complete form MC 250 if the placing state provides a Cert Letter certifying your child’s Medicaid eligibility under
Title IV–E. Please follow the instructions in paragraphs two through four above.
County Welfare Department Worker
The effective date of this application for Medi-Cal is the date this form is received in your department. This date must be entered
in the box designated for “County Use Only.” Upon receipt, check the form for completeness. If incomplete, contact the public
agency responsible for the named child or the adoptive/foster parents of the Title IV–E child placed by another state for the
necessary information. Only that information requested on form MC 250 is necessary to establish eligibility for a child not living
with a parent or relative and supported by public funds, except for the Title IV–E child placed by another state, now living in
California. These children must have a Cert Letter from the placing state certifying Title IV–E eligibility. A Notice of Action is to
be sent to the public agency or the adoptive/foster parents of the Title IV–E child when eligibility is established. Medi-Cal cards
are to be issued in the child’s name and sent to the person or child care facility with whom the child has been placed.
INSTRUCTIONS FOR USE OF FORM MC 250 FOR A DETERMINATION
Public Agency Representative or Adoptive/Foster Parents
Form MC 250 is to be completed by the Public Agency Representative at the time of the annual redetermination of Medi-Cal
eligibility for the child named on the reverse side of this form. Please complete the form in accordance with the application
instructions above and return it to us within 10 days so that we can certify continuous Medi-Cal eligibility. Adoptive/foster parents
need not complete the form annually. See instructions for county welfare department worker.
County Welfare Department Worker
Please complete the redetermination in accordance with the application instructions above for California placed children. For
Title IV–E children placed by another state, annually contact the placing state to verify child’s eligibility. Note changes on the
original MC 250 and take action accordingly.
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APPLICATION AND STATEMENT OF FACTS FOR CHILD NOT (Department of Health Care Services)

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Completed 30 July 2020

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