INFORMATION NOTICE
Unable to Verify United States (U.S.) Citizenship/
Identity Through The Social Security Administration
State of California - Health and Human Services Agency
Department of Health Care Services
MC 239 DRA-6 English (2/10)
Notice Date: _________________________________
Case Number: ________________________________
Worker Name: ________________________________
Worker Number: ______________________________
Worker Telephone Number: _____________________
Oce Hours: _________________________________
THIS NOTICE IS TO INFORM YOU THAT WE COULD NOT VERIFY YOUR U.S. CITIZENSHIP AND IDENTITY WITH
THE SOCIAL SECURITY ADMINISTRATION (SSA). THIS AFFECTS THE FOLLOWING PERSONS:
Insert Name(s) Here
Federal law requires non-exempt Medi-Cal applicants and beneciaries who claim to be U.S. Citizens or Nationals, to
provide evidence of their U.S. Citizenship/National status and identity. For most persons, this is done by verifying your
information with the SSA. However, the SSA was unable to verify that you are a U.S. Citizen or National.
Within 90 days, you will need to provide acceptable documentation of your U.S. citizenship and identity to your county
case worker. This is required to continue to receive full scope Medi-Cal benets.
• This 90-day period starts seven calendar days after the date of this notice.
• This notice is accompanied by information on which documents are acceptable. Please see “U.S. Citizens and
Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (DHCS 0001)” or “Proof of Citizenship
and Identity - New Requirements for Medi-Cal Beneciaries Who Are U.S. Citizens or Nationals (DHCS 0002).”
• If you are otherwise eligible for full scope Medi-Cal benets, you will receive these benets during the 90-day
period.
• If the county does not receive acceptable documentations from you, your benets will be reduced to limited
scope benets following the end of the 90-day period. We are NOT reducing your benets now. If your benets
are reduced in the future, another notice will be sent about that.
Limited benets only cover emergency, pregnancy-related, and long-term care services. If you are not sure if something
is an emergency, pregnancy-related, or a long-term care service, contact your medical provider.
You can also contact the SSA oce to resolve this matter. If the SSA agrees to update its records to reect your U.S.
citizenship and identity, you must inform your county case worker. The county will then resend their request to verify
your U.S. citizenship and identity.
This notice is required under Welfare and Institutions Code section 14011.2
