Fillable MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT (Department of Health Care Services)

Fill Online, Printable, Fillable, Blank MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT (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.

MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT (Department of Health Care Services)

On average this form takes 3 minutes to complete

The MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT (Department of Health Care Services) form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 13 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
 
State of California—Health and Human Services Agency Department of Health Care Services
MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT
TO: _______________________________________________________________________
(Receiving County)
FROM: _______________________________________________________________________
(Sending County)
SENDING COUNTY
: nd attach to the ICT packet.
Enclose a self-addressed return envelope.
Case name: ____________________________________________________________________
SSN and/or CIN: ________________________________________________________________
Worker name/worker code: ________________________________________ ______________
Worker phone number (including area code): __________________________________________
E-mail address: _________________________________________________________________
Complete this information a
/
RECEIVING COUNTY
:
Use the enclosed envelope to return to Sending County when the ICT packet has
been received/assigned.
ICT packet was received on .
(date)
Worker name/worker code: ________________________________________ ______________
Worker phone number (including area code): __________________________________________
E-mail address: _________________________________________________________________
Complete this information.
It has been assigned to:
/
MC 360 R (05/07)
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

MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT (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