Fillable MC 194 SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE (Department of Health Care Services)

Fill Online, Printable, Fillable, Blank MC 194 SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE (Department of Health Care Services) Form

Use Fill to complete blank online DEPARTMENT OF HEALTH CARE SERVICES (CALIFORNIA) pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MC 194 SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE (Department of Health Care Services)

On average this form takes 11 minutes to complete

The MC 194 SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE (Department of Health Care Services) form is 1 page long and contains:

  • 0 signatures
  • 19 check-boxes
  • 37 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Department of Health Care Services (California) forms online.

BROWSE DEPARTMENT OF HEALTH CARE SERVICES (CALIFORNIA) FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
B. Social Security Office Information
Name of SSA District/Regional Office
Address (number and street)
City State ZIP Code
D. Applicant/Recipient Information
Recipient’s name (last, first, middle initial)
Date of birth (month/day/year) Sex (M or F)
County ID per MEDS
Recipient’s SSN (if applicable) Case name
E. CWO Information
Name of Eligibility Worker
Date form completed E.W. Worker E.W. phone number
C. If the bearer of this form is either an applicant or a recipient of Food
Stamps, Cash Aid, or Medi-Cal, the following service is required:
☐ Original SSN card
☐ Duplicate SSN card SSN#:
☐ Info on SSA’s Data Bases (Numident, Title II, Title XVI, and
Medicare) needs to be verified.
☐ Name ☐ DOB ☐ Sex
☐ Info on SSA’s Data Bases (Numident, Title II, Title XVI, and
Medicare) needs to be corrected.
☐ Name ☐ DOB ☐ Sex
Note: Recipient must provide verification of change.
☐ Recipient has been assigned two SSNs. Please take action to
delete all but one.
☐ Two recipients appear to have been assigned the same SSN.
Please verify correct number for recipient from Numident File.
F. Comments
State of California – Health and Human Services Agency Department of Health Care Services
SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE
Instructions:
• To CWD: Please complete Part I. Retain original for your records, copy for recipient/SSA. Client must take this form to SSA.
• To Recipients: Read the back of this form. Take the necessary documentation to the Social Security Administration listed below in Part I B.
• To SSA: This form is a request for the action noted in Part I C. Please complete Part II of this form and distribute as noted in Part I A.
If you have any questions, the eligibility worker’s name and phone number are provided.
PART I: TO BE COMPLETED BY THE COUNTY WELFARE DEPARTMENT
A. Please enter the complete county welfare office name and address within the brackets provided.
SSA, after completion:
☐ FAX To:
☐ Mail this form to the county welfare office.
☐ Return this form to the recipient to be returned to CWD.
PART II: TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION DISTRICT/REGIONAL OFFICE
A. Date Received
B. Result of Referral
☐ Recipient has completed an SSN application (including Form
SS-5 and other proof) and application is being processed.
☐ Insufficient Identification
☐ SSN application is not being processed. (Explain)
☐ Other (Explain in Comments Section.)
C. Comments
D. SSA Representative – print name Signature Telephone Number
MC 194 (07/12)
SSA REFERRAL INFORMATION SHEET
(For Medi-Cal, Food Stamp, and CalWORKs Recipients)
YOU MUST CONTACT SOCIAL SECURITY
Public Law requires that each person who applies for or receives full-scope Medi-Cal, Food Stamps, or
California Work Opportunity and Responsibility to Kids must have or apply for a social security number.
For the applicant/ recipient noted on the reverse side, either (1) the Social Security Administration does
not have a social security number on file, or (2) the information provided by the Social Security
Administration and the information provided to the eligibility worker do not agree. To correct this situation,
you must contact the Social Security Office indicated on the reverse side of this referral form. DO NOT
MAIL THESE FORMS TO THEM.
NOTE: Age, citizenship or alien status, and identity must all be documented. One of the identification
documents must be a birth or baptismal certificate established BEFORE age 5. If one is not
obtainable, refer to Column A for acceptable substitutes. In addition, if the applicant/recipient is
a U.S. citizen born outside of the U.S. or an alien, one of the items listed in Column B must be
presented.
Column A
1. Evidence of Age/Citizenship
• School records
• Church records
• Census records (state or federal)
• Insurance policy
• Marriage records
• Draft card
• U.S. passport
• Other records indicating applicant’s age or
date and place of birth
2. Evidence of Identity
• Driver’s license
• State identification card
• Voter’s registration
• School records
• Health records (doctor’s, hospital’s, etc.)
• Any other document which shows
applicant’s signature, photograph, or
description
Column B
1. If you are now a U.S. citizen born outside the
U.S., take one of the following items in
addition to the item(s) required in Column A:
• U.S. citizen identity card
• U.S. passport
• Naturalization certificate
• Certificate of citizenship
• Consular report of birth
• Form I-179 (U.S. citizen card)
• Form I-197 (U.S. citizen resident card)
2. If you are an alien, take one of the following
items in addition to the item(s) listed in
Column A:
• Form I-151 or I-551 (Alien Registration
Receipt Card)
• Form AR3a, I-94, I-95a, I-84, I-85, I-86, or
SW-434
• Letters from Immigration and
Naturalization Service showing alien
status
If you have a question concerning the two identification documents which you must take to the Social
Security Office, please contact the Social Security Office.
MC 194 (07/12)
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MC 194 SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE (Department of Health Care Services)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 30 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document