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)