State of California – Health and Human Services Agency Department of Health Care Services
MC 373 (09/09)
COUNTY REFERRAL TO THE BREAST AND CERVICAL CANCER
TREATMENT PROGRAM
To:
Department of Health Care Services
Breast and Cervical Cancer Treatment Program
MS 4611
P.O. Box 997417
Sacramento CA 95899-7417
Phone number: 916-322-3410
Fax number:916-440-5693
From:
Name of County:
Name of Eligibility Worker (EW):
Phone number of EW:
Fax number of EW:
Applicant/Beneficiary Information:
Name:
Phone number:
Alternate/message phone
number:
Address:(number, street)
City: Zip Code:
Authorized Representative:
Yes No
AR Name: AR Phone number:
Applicant’s/beneficiary’s
primary Language:
Case number:
CIN:
Case Information (check all that apply):
Referral is for an applicant.
Referral is for a beneficiary.
Case referred to the Disability Determination Service Division – State Programs for a
disability evaluation
Beneficiary put into an SB-87 Pending Disability aid code (6J, 6R, 5J or 5R).
Comments:
