State of California—Health and Human Services Agency Department of Health Care Services
MEDI-CAL ANNUAL REDETERMINATION FORM
You must ll out this form and return it to the county to keep your Medi-Cal!
Case Number (optional) Social Security Number (optional)
Print Your Full Name (if you have not moved, put address label here if one is provided) Birth Date (optional) (mm/dd/yyyy)
Current Street Address, Apartment Number (check here if address is new)
City/State Zip Code
Mailing Address
(if different from above) City/State Zip Code
Use ink and PRINT your answers. Make sure you sign and date the form. Use the postage paid envelope to return it. If you
need more space, attach a separate sheet to this form. If you have any questions or need helplling out this form, call your
worker at the telephone number listed on the Annual Redetermination Notice.
Section 1. Income
(a) Do you or any family member in the home get money from a job, child support or alimony, social
security, veteran benets, unemployment or disability benets, retirement, gifts, or interest or
dividends? Yes No
If yes, complete below and list each source of income on a separate line.
Attach most recent pay stubs showing income before taxes or deductions, benefit or award letters,
checks received or signed statement from employer, or last years federal income tax return. If income
is from self-employment, send a copy of your most recent tax return or profit and loss statement.
Name of Person with Income
(include rst and last name) Source of Income
Income Amount
(before any
deductions)
How Often Paid
(weekly, monthly,
twice a month)
Hours Worked
(per week or
month)
(b) Do you or any family member in the home get rent, utilities, food, or clothing entirely free? Yes No
If yes, who?
What was free?
(c) Was the free rent, utilities, food, or clothing received in exchange for work done? Yes No
MC 210 RV (5/11) Page 1 of 4
State of California—Health and Human Services Agency Department of Health Care Services
Section 2. Expenses and Deductions
Do you or any family member in the home pay for child or adult care, health insurance or Medicare
premiums, court-ordered child support or alimony, or educational expenses?
Yes No
If yes, complete below and list each expense/deduction on a separate line.
Attach proof of expenses/deductions.
Name of Person
with Expense/Deduction
(include rst and last name)
Type of
Expense or
Deduction
Amount of
Payment Paid to Whom
How Often Paid
(weekly, monthly,
twice a month)
Section 3. Other Health Insurance
(a) Did you or any family member have a change in, or get new health, dental, vision, or Medicare
coverage or insurance within the last 12 months?
Yes No
If yes, who has the coverage/insurance?
Which type of coverage/insurance?
(b) Is any family member living in the home receiving kidney dialysis-related services? Yes No
If yes, who?
(c) Has any family member living in the home received an organ transplant within the last 2 years? Yes No
If yes, who?
Section 4. Living Situation
(a) Did anyone move into or out of your home, move in with someone else, get married, or have a baby
within the last 12 months? (Examples: newborn, child, or adult moved in or out of the home, absent
parent returns home.)
Yes No
If yes, complete below:
Name (include rst and last name) Relationship to You What Changed? Date Changed
(b) Does anyone in the home want Medi-Cal who is not already receiving it?
Yes No
If yes, who?
(c) If a new baby is in home, where was the baby’s place of birth? | |
City State Country
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State of California—Health and Human Services Agency Department of Health Care Services
Section 4. Living Situation
continued
(d) Did anyone in the home get inpatient care in a nursing facility or medical institution?
Yes No
If yes, who?
(e) Is anyone in the home pregnant? Yes No
If yes, who?
Number of babies expected Due date:
Section 5. Real or Personal Property
(a) Indicate the total amount of cash and uncashed checks held by any family member in the home $
(b) Does anyone have a checking or savings account, life insurance, long-term care insurance,
motor vehicle, court-ordered settlement or judgement, stocks, bonds, retirement funds, trusts
where money or property is held for the benet of any family member in the home, real estate,
motor vehicles for a business, business accounts or property, promissory notes, mortgages,
deeds of trust, recreational vehicles, burial trusts or funds, annuities, jewelry (not heirloom or
wedding), or oil or mineral rights?
Yes No
(c) Did you or any family member in the home sell or give away any money or property in the
past 12 months, or have any of the items listed in this section been spent or used as security
for medical costs? Yes No
Note: If you have answered “yes” to questions (b) or (c), you will also have to fill out a property
supplement form, submit the form to the county and provide verification.
Section 6. Immigration or Citizenship Status Change
Has there been a change in immigration or citizenship status for anyone in the home that has Medi-Cal
or wants Medi-Cal within the last 12 months? (If your immigration status has changed, you might qualify for
full scope Medi-Cal benets.)
Yes No
If yes, list the name(s) below and send proof of new status.
Name of Person
(include rst and last name)
Status Change
(send proof of status)
Section 7. Blindness/Disability/Incapacity
(a) Do you or any family member in the home have a physical or emotional condition that makes it
difcult to work, take care of personal needs, or take care of your children?
Yes No
If yes, who?
(b) Was the physical, mental, or health condition a result of an injury or accident? Yes No
If yes, explain
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State of California—Health and Human Services Agency Department of Health Care Services
Section 8. Other Health Program Information and Referrals
(a) Check this box if you do not want your childs information shared with the low-cost Healthy
Families Program if your child gets Medi-Cal with a share of cost.
(b) Do you want information on the no-cost health program for children under 21 (Child Health
and Disability Prevention Program, also known as CHDP?)
Yes No
(c) Do you want information on the no-cost supplemental food program for pregnant or breast
feeding women and children under 5 (Women, Infants, and Children Program, also known
as WIC)? Yes No
(d) Do you want information on the Personal Care Services Program, an in-home care program
for aged, blind, or disabled persons (also known as In-Home Supportive Services)?
Yes No
Section 9. SignatureandCertication
Person completing this form must read and sign below.
I have received and read a copy of the Important Information for Persons Requesting Medi-Cal form (MC 219).
I am aware of, understand, and agree to meet all my responsibilities as described on the MC 219 form.
I certify that I will report all income, property, and/or other changes that may affect Medi-Cal eligibility within
ten days of the change.
I understand that all of the statements, including benefit and income information, that I have made on this
form, may be subject to investigation and verification.
I declare, under penalty of perjury, under the laws of the State of California that all information provided on this
form is true and correct.
Signature Date
Daytime or Message Telephone Number
Home Telephone Number
(check here if new number)
Signature of Witness (if signed by a mark), Interpreter or Person Assisting
County Use Only
Referrals Follow-up Forms
HF
CHDP
WIC
PCSP
MC 13
MC 210 PS
DDSD Packet
Other:
MC 210 RV (5/11) Page 4 of 4
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