Fill - Free fillable )U.S.( Social Security Administraton (Department of Health Care Services) PDF form



)U.S.(

 Social Security Administraton

State of California - Health and Human Services Agency

Department of Health Care Services

MC 239 DRA-6 Farsi )2/10(

Notice Date: _________________________________

Case Number: ________________________________

Worker Name: ________________________________

Worker Number: ______________________________

Worker Telephone Number: _____________________

Oce Hours: _________________________________

)U.S.(

)SSA( SOCIAL SECURITY ADMINISTRATION



Medi-Cal 

SSA SSA



90

 Medi-Cal 

•  90

•  “ 

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

–  “  ”)DHCS 0001( Medi-Cal 

”)DHCS 0002(  Medi-Cal 

• 90Medi-Cal

• 90







SSASSA





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

Welfare and Institutions Code section 14011.2

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