State of California—Health and Human Services Agency
Department of Health Care Services
NOTIFICATION OF MEDI-CAL INTERCOUNTY TRANSFER
Instructions: Complete each space or box. If information does not pertain to this case, indicate with N/A.
Receiving county name and address Sending county name and address
Case Name/Beneficiary Information
Case name Phone number
(
Alternate phone number
(
Address (number, street) City ZIP code
Authorized representative (AR)
Yes No
AR name AR phone number
(
Beneficiary’s primary language
) )
)
Receiving county follow-up on changes related to intercounty transfer
Medi-Cal Family Budget Unit (If person is excluded, please indicate.)
Name Aid Code Income/How Often Received Share-of-Cost (SOC)
Other Case Information
CE for: _________________________________________
CEC for: ________________________________________
CEC period: _____________________________________
TMC period: _____________________________________
Annual redetermination due date: ___________________
LTC period of ineligibility: __________________________
Court case: _____________________________________
Other: _________________________________________
Documents in Transfer Packet
Statement of Facts and applicable supplements/MC 210 RV
Social security card(s)
Identifications
Case narrative
Budget work sheets for MFBU/MBU
Computer generated case documents
Last NOAs for share-of-cost
Income verifications
Other Health Coverage Information (DHCS 6155)
Pregnancy verification for: _________________________
Primary wage earner: _____________________________
MC 13s and Proof of Alien Status for: ________________
_______________________________________________
Property verifications or MC 176 P
Family Support Information (CW 2.1s)
Authorized Representative Form/Letter
SP-DDSD Decision/Incapacity Verification for: _________
_______________________________________________
Other(s) (list): ___________________________________
Sending County Worker Information
Worker name Worker number Date ICT packet sent
Phone number
(
Fax number
(
E-mail address
) )
MC 360 (06/07)
