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Mc2600 Health Insurance Information

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State of California—Health and Human Services Agency Department of Health Care Services
CALIFORNIA CHILDREN’S SERVICES
HEALTH INSURANCE INFORMATION
Medical Insurance
Dental Insurance
Patient’s name CCS number County
Type of insurance plan (check one)
Major medical
Preferred Provider Organization (PPO)
Health Maintenance Organization (HMO)
1.
Name of insurance plan Policy identification/group number Effective date of policy
Claims office address (number, street) City State ZIP code Phone number
(
2. Policy holder’s name Social security number
Address (number, street) City State ZIP code
3. Employer of insured Phone number
(
Address (number, street) City State ZIP code
4. Union name Local number
Address (number, street) City State ZIP code
)
)
DESCRIPTION OF INSURANCE BENEFITS
Child’s Professional Care (Maximum Amount)
Coverage
Yes No Extent Child’s Hospital Care (Maximum Amount)
5. Office visits $ 13. Yes No
6. Outpatient, x-ray, laboratory $ $________________ per day for
7. Surgery $ 14. $
8. Assistant surgery $ 15.
9. Anesthesia $
10. Hospital visits $
11. Other $
12. Limitations:
16. Major medical or extended benefits Yes No
Room and board
___________days
Miscellaneous hospital services
Limitations:
Yes
No Yes No Yes No
Prescriptions  Brace repairs  Dental plan 
Glasses/repair  Hearing aids  Orthodontics 
Braces  Hearing aid accessories  Other: 
17. Deductible $_______________ at _________% per Calendar year
Benefit year
If benefit year, effective date
____________________________ If newborn, effective date of policy
18.
Maximum benefits
$_______________ per
Lifetime of policy:
Illness Year
19. I agree to repay California Children’s Services any insurance proceeds improperly diverted by me. I acknowledge the Privacy Statement
on the back side of this form.
Signature of parent or legal guardian Date
Report completed by Title Date
MC 2600 (09/07)
PRIVACY STATEMENT
The information on this form is required by the county and state California Children’s Services
(CCS) as part of your application for assistance, as CCS cannot pay for that portion of expenses
which are a benefit of your insurance resource. The information is maintained pursuant to
Section 123800, et seq., of the California Health and Safety Code. You are required to provide
the information on this form. If you do not provide this information, eligibility for services may be
denied. Any information which you provide may be used by county and state CCS offices, the
California Department of Health Care Services, and providers of services. You have a right to
review records maintained by CCS concerning you. If you wish to review these records,
contact the person responsible for the records in your county CCS office. Appeals may
be directed to: Branch Chief, Children’s Medical Services (CMS) Branch, MS 8100, P.O.
Box 997413, Sacramento, CA 95899-7413 (telephone (916) 327-1400). After reviewing your
records you may request in writing that they be corrected or amended to make them
accurate, relevent, and complete.
MC 2600 (09/07)
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Mc2600 Health Insurance Information

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Completed 3 July 2020

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