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: ___________________________________
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
CF 31 (4/15) Recommended Form
PAGE 2 OF 2
The supplemental form for special medical deductions is for any CalFresh household member who is elderly or disabled.
When we say “elderly” we mean anyone who is age 60 or older.
When we say “disabled” we mean anyone who is getting:
1) Disability payments from the Social Security Administration (SSA) (other than Supplementary Security Income/State
Supplementary Program (SSI/SSP)) or the Veterans Administration (VA); OR
2) Disability retirement benefits from a federal, state or local governmental agency or the Railroad Retirement Board; OR
3) Medi-Cal services because of a disability; OR
4) Interim assistance/emergency general relief while waiting to get SSI/SSP because of a disability approved by the Social Security
Administration.
Examples of Verifications:
Medical bills or receipts
Medical transportation bills or receipts
Health or dental insurance policies or premiums
Medicare card (for Medi-Cal only)
Doctor statement or disability finding by an agency (SSA/SDI/VA, etc.)
Medical verification form (CW61)