Fillable Social Security Administration (Department of Health Care Services)

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Social Security Administration (Department of Health Care Services)

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
)U.S.(/
Social Security Administration
State of California - Health and Human Services Agency
Department of Health Care Services
MC 239 DRA-6 Arabic )2/10(
Notice Date: _________________________________
Case Number: ________________________________
Worker Name: ________________________________
Worker Number: ______________________________
Worker Telephone Number: _____________________
Oce Hours: _________________________________
.SOCIAL SECURITY ADMINISTRATION )SSA(


 Medi-Cal
 .SSA 
SSA
 
 90
 Medi-Cal
• 
90
• “ 
“ ”)DHCS 0001( Medi-Cal
”.)DHCS 0002( Medi-Cal
•
 90 Medi-Cal

• 
90
 

 

 SSA  SSA

 
Welfare and Institutions Code section 14011.2
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Social Security Administration (Department of Health Care Services)

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Completed 30 July 2020

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