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MEDI-CAL LONG-TERM CARE FACILITY ADMISSION AND DISCHARGE NOTIFICATION (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services
MC 171 (05/07)
MEDI-CAL LONG-TERM CARE FACILITY ADMISSION AND DISCHARGE NOTIFICATION
(Instructions and distribution on reverse.)
I. COMPLETE THIS PORTION FOR ALL ACTIONS
Patient’s name (last) (first) (MI)
Name of facility
Social security number
Address (number and street)
Note: Level of care is SNF/ICF unless checked
here as board and care.
City
State
ZIP code
II. COMPLETE THIS PORTION ONLY FOR ADMISSIONS
Medi-Cal ID number (taken from the Medi-Cal card)
Admission date (month/day/year)
E. Admission from:
Home Board and Care
Household of another
Acute Hospital—Home, B&C, other household immediately
prior to acute
Acute Hospital—SNF/ICF immediately prior to acute
Acute Hospital extended stay—over 30 days
Another SNF/ICF
F. If known, enter your address prior to facility admission. If
admitted from an acute hospital, enter your address prior to the
acute hospital admission. (Do not give the acute hospital’s
address.)
Address (number and street)
A. Do you have Medicare Part A, Hospital Coverage?
Yes No
B. Expected length of stay:
At least one full month after the month of admission
Less than one full month after the month of admission
C. Medi-Cal is expected to pay over 50% of facility cost of care.
Yes, beginning with month of , 20
No, other insurance, private pay, etc.
D. Current income (check all applicable boxes):
Supplemental Security Gold Checks
Social Security Green Checks
Other Income (i.e., railroad, military retirement, etc.)
None
City
State
ZIP code
G. Signature of recipient or representative payee or family member/other:
Signature of recipient Signature of Representative Payee Phone number
If recipient’s signature cannot be obtained, please indicate reason in this space.
Signature of family member/other (Indicate your relationship to the recipient.) Phone number
III. COMPLETE THIS PORTION ONLY FOR DISCHARGES
A. Reason for discharge:
B. Date of discharge (month/day/year)
C. Medi-Cal ID number (taken from the Medi-Cal card)
D. Complete the forwarding address for discharges other than death:
Name of facility (if not discharged home)
Address (number and street)
Discharged to Acute Hospital
Discharged to another SNF/ICF
Discharged to residence/home of another
Discharged to Board and Care
Discharged to other
Discharge due to death
City
State
ZIP code
Facility representative signature Date
MC 171 (05/07)
I. General Instructions
This form is to be used for each admission and discharge. Please do not use this form for Medi-Cal
reauthorizations.
II. Admission Instructions
A. Preparation
Prepare an original and two copies of this form for each SSI/SSP and/or Medi-Cal admission.
B. Distribution
Original: Send to your local social security office for recipients with aid codes 10, 20, and 60.
Send to the county welfare department (see attached list) for all other aid codes.
Copy 1: Attach to the Treatment Authorization Request (TAR) and send to the Department of
Care Health Services, Medi-Cal field office in your area. It will be forwarded
by the Medi-Cal field office to the county welfare department.
Copy 2: Retain for your file.
III. Discharge Instructions
A. Preparation
Prepare an original and two copies of this form for each SSI/SSP and/or Medi-Cal discharge.
Instead of completing a new form, use copy two of the form retained in your file as part of the
admissions process. Complete Part III of the form (which becomes the original for the discharge
process), and make two copies.
B. Distribution
Original: Send to the Medi-Cal field office.
Copy 1: Send to the county welfare department (see attached list).
Copy 2: Retain for your file.
IV. Explanation of over 50% of cost of care mentioned in item II.C. of this form.
Cost of care is the daily charge per patient excluding any additional services rendered to the patient
which are billed separately by other providers (i.e., ambulance, physician, pharmacy, etc.).
For example, if the daily rate is $30 per day, the monthly charge for a 30-day month would be $900.
If a patient enters the facility during the month of January, and is expected to stay at least one full
calendar month after the month of admission (through February), a “YES” response would be
indicated for item II.C. if Medi-Cal is expected to pay over $450 of the $900 charge for February.
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MEDI-CAL LONG-TERM CARE FACILITY ADMISSION AND DISCHARGE NOTIFICATION (Department of Health Care Services)

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Completed 30 July 2020

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