STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CALFRESH SUPPLEMENTAL FORM FOR SPECIAL MEDICAL DEDUCTIONS
CF 31 (4/15) Recommended Form
PAGE 1 OF 2
This form is for special medical deductions for any CalFresh household member who is elderly or disabled. See the other side of this
page for what we mean when we say “elderly or disabled.”
Are you, or anyone you buy and prepare food with, an elderly (60 or older) or disabled person that has any out-of-pocket medical
expenses?
■
Yes
■
No
If yes, please check all the boxes of the types of medical expenses that apply from these examples listed below (there may be others
not listed here). List expenses you expect to have during the certification period. Please complete the section below and attach bills,
receipts, or proof of expenses.
NOTE: Don’t list spouses or children receiving dependent payments from Social Security Administration (SSA) Veteran’s Administration
(VA), etc. Allowable medical expenses are:
■
Medical or dental care
■
Prescribed over the counter
medications
■
Dentures, hearing aids and
prosthetics
■
Prescribed eye glasses
contact lenses
■
Maintaining an attendant
necessary due to age,
illness, or infirmity
■
Hospitalization or outpatient
treatment/nursing care
■
Health and hospitalization
insurance policy premiums
■
Prescribed medical supplies and
equipment
■
Cost of transportation (mileage
or fee) treatment or services
■
The number and cost of meals
furnished to an attendant
■
Prescribed medication
■
Medicare premiums (Medi-Cal
share of costs, etc.)
■
Service animals (i.e. seeing eye
or hearing dog) expenses (food
and vet bills, etc.)
■
Cost of lodging to obtain medical
and to obtain medical treatment
or services
■
Other (specify)
Name of elderly or disabled
person
What type of
expense?
(prescriptions,
dentures, # of meals
for attendant, etc.)
Amount of
expense?
How often paid?
(monthly, weekly,
other)
Will the household be
reimbursed for any
medical expenses?
(By Medi-Cal, insurance,
etc.)
If yes, by who:
How much $
If yes, by who:
How much $
If yes, by who:
How much $
If yes, by who:
How much $
If yes, by who:
How much $
$
$
$
$
$
Case Name: ______________________________________ Case Number: ___________________________________
