Beneficiary Information
Name:
Social Security Number:
Date of Incarceration:
Institution Name:
Note: All fields on this form must be completed. Upon receipt of this form, MCIEP analyst will
forward this information to the Social Security Administration.
_________________________________________________________
_________________________________________________________
_________________________________________________________
State of California
Health and Human Services Agency
Department of Health Care Services
County Transmittal for
Medi-Cal Inmate Eligibility
Program (MCIEP)
Applicants Receiving Social
Security Income (SSI)
DATE:
TO:
FROM:
SUBJECT:
MCIEP@dhcs.ca.gov
Medi-Cal Inmate Eligibility Program
(916) 440-5651
MCIEP Secure Fax Number
County Staff Name
Phone Number and Email Address
County Name
Reporting of a Medi-Cal beneficiary who is currently incarcerated and is a recipient of
Social Security Income Only
Confidentiality Notice:
The information contained in this E-mail / Fax document is confidential and intended only to be viewed bythe
recipient listed above. If you are not the intended recipient (or the employee or agent responsible to deliver this to
the intended recipient), you are hereby notified that any distribution or copying of this document is strictly prohibited.
If you have received this document in error, please contact the sender listed above and destroy the document.
1501 Capitol Avenue, MS 4607, P.O. Box 997417, Sacramento, CA 95899-7417
(916) 552-9430 phone, (916) 552-9477 fax
