____________________________________________________ ________________________
State of California—Health and Human Services Agency Department of Health Care Services
Medi-Cal Program
FOR COUNTY USE ONLY
Case name: __________________________________________
Case number:
___________________________
Worker number: _______________________________________
Telephone number: ____________________________________
REQUEST FOR WITHDRAWAL AND/OR WAIVER
OF TEN-DAY ADVANCE NOTICE
❒ MEDI-CAL APPLICATION WITHDRAWAL
I, ________________________________________________________, ask that my application for Medi-Cal, dated
_____/_____/_____, be withdrawn because _____________________________________________________________
.
I understand that my Medi-Cal eligibility will not be determined at this time. I can reapply at any time.
❒ MEDI-CAL ELIGIBILITY DISCONTINUANCE
I, ________________________________________________________, ask that my Medi-Cal eligibility be discontinued
effective _____/_____/_____ because _________________________________________________________________
.
I understand that I can reapply at any time.
❒ BENEFICIARY WAIVER OF TEN-DAY NOTICE
I, _________________________________________________________, understand that based upon the information I
have reported, effective _____/_____/_____,
❒ my Medi-Cal eligibility must be discontinued.
❒ my Medi-Cal share-of-cost must be increased.
I understand that I am supposed to be given a ten-day notice before this action becomes effective. However, since I know that
the above action must be taken based on the information I reported, it is not necessary for the county to send me this notice
within the ten-day limit.
I understand that the above request will not interfere with my right to a state hearing, and that I can reapply for Medi-Cal at any
time. I understand that if I ask for a state hearing before the effective date of the action, the county’s action will be delayed.
Signature of Applicant/Beneficiary Date
MC 215 (05/07)
