Fillable Mc176tmc TRANSITIONAL MEDI-CAL (TMC) QUARTERLY STATUS REPORT (Department of Health Care Services)

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Mc176tmc TRANSITIONAL MEDI-CAL (TMC) QUARTERLY STATUS REPORT (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services
MC 176 TMC (05/07)
TRANSITIONAL MEDI-CAL (TMC)
QUARTERLY STATUS REPORT
This status report is for the months of Return this form no later than
Month 1 Month 2 Month 3 the 21st day of
IMPORTANT: COMPLETE, SIGN, AND RETURN THIS REPORT TO THE WELFARE DEPARTMENT IN THE ENCLOSED ENVELOPE.
Attach proof of your income, actual child care expenses paid, and total hours of employment for the three months noted above. If you have
any questions regarding this form or the items to be reported, contact your eligibility worker.
● For Transitional Medi-Cal (TMC)—You will receive status reports during this period. If you do not complete and return these reports,
your eligibility for TMC will be discontinued.
PART A. DISCONTINUANCE REQUEST
I request that my Transitional Medi-Cal be stopped on the last day of _____________________
Month/Year
I know that I can reapply for Medi-Cal at any time. ______________________________________________ ____________________
Applicant signature Date
IF YOU WANT YOUR TMC ELIGIBILITY TO CONTINUE, PLEASE COMPLETE AND SIGN PART B OF THIS REPORT.
PART B. ELIGIBILITY STATUS INFORMATION
1. Did anyone receive any income, money, or benefits during the report period such as salary, wages, tips,
commissions, bonuses, vacation pay? If yes, attach proof (all pay stubs) for each report month. ❒ Yes ❒ No
Name Month 1 Month 2 Month 3
Income received? ❒ Yes ❒ Yes ❒ Yes
Employer/source ❒ No ❒ No ❒ No
Total hours worked: __________ __________ __________
Name Month 1 Month 2 Month 3
Income received? ❒ Yes ❒ Yes ❒ Yes
Employer/source ❒ No ❒ No ❒ No
Total hours worked: __________ __________ __________
Name Month 1 Month 2 Month 3
Income received? ❒ Yes ❒ Yes ❒ Yes
Employer/source ❒ No ❒ No ❒ No
Total hours worked: __________ __________ __________
Name Month 1 Month 2 Month 3
Income received? ❒ Yes ❒ Yes ❒ Yes
Employer/source ❒ No ❒ No ❒ No
Total hours worked: __________ __________ __________
2. Did you or any family member receive money or benefits from other sources such as disability, unemployment,
child support, or social security? If yes, attach proof (all pay stubs) for each report month. ❒ Yes ❒ No
Name Month 1 Month 2 Month 3
Income received? ❒ Yes ❒ Yes ❒ Yes
Employer/source ❒ No ❒ No ❒ No
Name Month 1 Month 2 Month 3
Income received? ❒ Yes ❒ Yes ❒ Yes
Employer/source ❒ No ❒ No ❒ No
Name Month 1 Month 2 Month 3
Income received? ❒ Yes ❒ Yes ❒ Yes
Employer/source ❒ No ❒ No ❒ No
MC 176 TMC (05/07)
3. a. Did you or any family member receive free housing, utilities, food, or clothing in the report month? ❒ Yes ❒ No
b. Did you or any family member work for housing, utilities, food, or clothing in the report month? ❒ Yes ❒ No
If yes to 3a and 3b, you must answer the three questions on the next line.
(1) What was received? (2) Who received it? (3) Who provided it?
4. Did you or anyone pay for child care expenses which have not or will not be reimbursed? ❒ Yes ❒ No
If yes, complete the following:
Amount Paid for Child Care Expenses
Name of Child(ren) Age Month 1 Month 2 Month 3 Name of Child Care Provider
5. Did you have changes in your family or household during the time specified? (Include change of address,
change of child care provider, change of employment, change in property, anyone that moved into or out
of your home, is pregnant, or anyone who was born or who died.) ❒ Yes ❒ No
If yes, complete the following:
Name Relationship What Happened Date
6. a. Do you or anyone have or expect to receive private health, vision, or dental insurance? (This includes
insurance paid by an absent parent.) ❒ Yes ❒ No
b. Do you have or expect to receive health insurance through your employer? ❒ Yes ❒ No
c. Does your employer offer health insurance for a monthly premium? ❒ Yes ❒ No
If yes, complete the following:
Name of Insurance Person(s) Insured
CERTIFICATION
I understand that reported facts may result in benefits being changed or stopped.
I understand that the statements I have made on this form are subject to investigation and verification.
I understand that I must notify my worker within ten days of any change.
I understand that failing to report facts or giving wrong or incomplete facts can result in legal prosecution with penalties of a fine,
imprisonment, or both.
I DECLARE UNDER PENALTY OF PERJURY UNDER THE LAWS OF THE UNITED STATES AND THE STATE OF CALIFORNIA THAT
THE INFORMATION CONTAINED IN THIS REPORT IS TRUE AND CORRECT AND IS COMPLETE FOR THE ENTIRE REPORT PERIOD.
Signature or mark of applicant Date Phone number
( )
Signature of witness to mark, interpreter, or other person Date Phone number
( )
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Mc176tmc TRANSITIONAL MEDI-CAL (TMC) QUARTERLY STATUS REPORT (Department of Health Care Services)

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Completed 30 July 2020

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