State of California—Health and Human Services Agency Department of Health Care Services
TRANSMITTAL TO CDCR PUBLIC BENEFIT SPECIALIST ON
DETERMINATION OF A WARD’S/INMATE'S MEDI-CAL ELIGIBILITY
Date: CDCR Number:
Benefits Information for:
ELIGIBILITY PENDING (Note: The eligibility status information provided below is subject to
change if all eligibility requirements are not met at the time the ward/inmate is released.
This ward/inmate will be eligible to receive no-cost Medi-Cal benefits
beginning on the following date: __________________.
This ward/inmate will be eligible to receive Medi-Cal benefits with a share-of-
cost beginning on the following date: ___________________.
This ward/inmate will be eligible to receive limited Medi-Cal benefits
beginning on the following date: ___________________.
Due to a change of his or her release date, this ward/inmate will not be
eligible to receive Medi-Cal on ___________________; instead he or she will be
eligible to receive Medi-Cal benefits on the following date: _________________.
ELIGIBILITY DENIED
This ward’s/inmate’s application for Medi-Cal, dated __________________,
has been denied. The reason for this denial is:
INFORMATION REQUEST (Please contact the County immediately if you have questions
or concerns regarding the denial of eligibility)
In order to determine the ward’s/inmate’s eligibility we need the following
information:
MC 0025 (3/10)
