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MC 262 (06/07) Page 1 of 4
State of California—Health and Human Services Agency Department of Health Care Services
REDETERMINATION FOR MEDI-CAL BENEFICIARIES
(LONG-TERM CARE IN OWN MFBU)
INSTRUCTIONS: Your continuing eligibility will be decided on the information you give on this form. If you are completing this
form on someone else’s behalf, the term “you” applies to that person. ALL QUESTIONS MUST BE ANSWERED.
1. Name (first, middle, last) Date of birth (month, day, year) Social security number
2. Long-term care facility name Marital status Medicare claim number
Facility address (number, street) City ZIP code
3. Name of spouse Social security number Telephone
(
Address of spouse (number, street) City State ZIP code
4. Name of person helping complete form Relationship Telephone
(
)
)
5. Address of person helping with form (if information regarding beneficiary should be sent to this person)
Number, street City State ZIP code
6. Do you own any real property, have an interest in real property, or own a trailer or mobile home taxed
as real property? ...................................................................................................................................... U Yes U No
If yes:
a. Is this property your former home? ..................................................................................................... U Yes U No
If yes, do you intend to return to that property to live in the future?.................................................... U Yes U No
(If this intent changes, you must notify the county within 10 days.)
If you do not intend to return to that property, does anyone else live there now? .............................. U Yes U No
If yes, enter name:___________________________________Relation to you: ____________________________
Basis of dependency (financial, medical, etc.) ______________________________________________________
How ________________________________________________________________
b. Is this property currently listed for sale? ............................................................................................. U Yes U No
Description of property: ________________________________________________________________________
Address of property: __________________________________________________________________________
Owner(s):___________________________________________________________________________________
Full value (from tax statement): $ ___________________ Amount owed: $ ___________________
Rent collected each month: $ ___________________ Expenses on property: $ ___________________
Interest $ ____________ U Yearly U Monthly Insurance $ ___________ U Yearly U Monthly
Taxes and assessments $ ____________ U Yearly U Monthly
Upkeep and
Utilities $ ____________ U Yearly U Monthly repairs ___________ U Yearly U Monthly
7. Do you have a life estate in any property? ............................................................................................... U Yes U No
If yes, describe:_________________________________________________________________________________
8. Do you own a note, mortgage, or deed of trust? ...................................................................................... U Yes U No
If yes: Appraised value _____________ Monthly payment: $ ______________ Interest rate: ___________%
9. Do you have any checks or money on hand in banks, savings and loans, or credit unions, etc.
(checking or savings accounts), or a patient trust account, or a trust or agreement where money or
property is being held for your benefit or being held for you by anyone, or being kept anywhere
for you? .................................................................................................................................................... U Yes U No
If yes:
a. On hand? _________________________________________________________
Location Amount Account number
b. In bank or savings? _________________________________________________________
Location Amount Account number
_________________________________________________________
Location Amount Account number
c. Held or kept for you by anyone? _________________________________________________________
Location Amount Account number
COUNTY USE ONLY
PR U Yes U No
U DHCS 7014
Utilized U Yes U No
$_________________
Current month income
U Yes U No
$_________________
$_________________
$_________________
$_________________
long have they lived there?
$
$
included
Relation to you:
Utilities
Location
PR
10. Have you sold, transferred, or given away any property (including money) at any time in the past year? U Yes U No
If yes:
Date of Transfer, Amount
Description Sale, or Gift Value Received
$
$
$
11. Do you own any of the following items of property?
Yes No Purchase Price Current Value Amount Owed
a. Stocks or bonds, certificates of deposit, money market,
or mutual fund account $ $ $
b. Jewelry valued over $100 (other than wedding or
engagement heirlooms) $ $ $
c. Burial reserve or trust $ $ $
d. Burial plot, vault, or crypt $ $ $
e. Business equipment, tools, inventory, or material $ $ $
f. Other $ $ $
12. Do you own any annuities or life insurance policies or long-term care insurance policies for yourself or
anyone else? ............................................................................................................................................ U Yes U No
If yes:
Current
Company Name of Insured or Annuitant Face Value Cash Value
a. $
b. $
c. $
13. Do you own a motor vehicle (car, truck, etc.); or a boat, camper, or motor home; or mobile home or
trailer not taxed as real property?............................................................................................................. U Yes U No
If yes:
Class Code
Description (From Registration) Year Purchase Price Amount Owed
$
$
14. Do you or your spouse receive any income? ........................................................................................... U Yes U No
If yes, list the source and amount of income received each month.
indicate how often received.
When Paid/How Often Applicant Spouse
Social Security (green check) $ $
SSI/SSP $
Railroad retirement $ $
Veterans benefits (including Aid and Attendance payments) $ $
Retirement or pension $ $
Annuities $
Interest income or dividends $ $
Contributions (including those from relatives) $ $
Earnings (gross) $ $
Other (include lump sum payments, inheritance, etc.) $ $
15. a. .................................................. U Yes U No
b.
military service? .................................................................................................................................. U Yes U No
16. Have you applied for or do you think you are eligible for any payments you are not now receiving? ...... U Yes U No
If yes:
Kind of Payment Date Applied For Date Expected
U Verification
$_________________
U Exempt
$_________________
$_________________
$_________________
$_________________
Verification of CSV on file?
$_________________
Copy of annuity on file?
U Yes U No
State certified LTC policy?
U Yes U No
Amount paid out $___________
DHCS 6155 completed
U Yes U No
Exempt U Yes U No
$_________________
Use copy of award letter or
check or other verification
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
$_________________
CA5 (if not already completed)
$
$
$
If yes, provide the other information requested. Check yes or no.
$
$
$
$
$
If income is received less often than monthly,
Attach verification of this income.
$
$
Have you or any family member ever been in U.S. military service?
Are you or any family member the spouse, parent, or child of a person who has been in U.S.
MC 262 (06/07) Page 2 of 4
Yes
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes No
Yes
No
17.
Do you have Medicare coverage?............................................................................................................ U Yes U No
If yes:
Name Medicare claim number Monthly premium
Deduction from check? U Yes U No
Paid by you? U Yes U No
18. Do you have health or hospitalization insurance?.................................................................................... U Yes U No
If yes:
Name of insurance company
Premium you pay How often?
$ U Monthly U Quarterly U Yearly
19. Would you like to speak to a social worker about services available to you? .......................................... U Yes U No
If yes, explain the services you wish to discuss:
20. Additional information
Date verified
DHCS 6155 completed?
U Yes U No
OHC Code ________________
Service Referral U Yes U No
BE SURE YOU HAVE READ EVERY ITEM AND ANSWERED ALL THE QUESTIONS.
READ THE FOLLOWING CAREFULLY BEFORE SIGNING.
I declare under penalty of perjury that the answers I have given are correct and true to the best of my knowledge.
I agree to tell the county welfare department within ten days if there are any changes in my (or the person’s on whose behalf I am acting) income, possessions,
or expenses, or a change in my living situation. I agree to meet all the other responsibilities explained in the “Important Information for Persons Requesting
Medi-Cal” (MC 219) I received at the time of my application for Medi-Cal. (A new “Important Information for Persons Requesting Medi-Cal” (MC 219) will be
provided if there is a change in the person acting on behalf of the beneficiary.)
I understand that Section 1137 of the Social Security Act requires that I provide my Social Security number (SSN). My SSN will be verified and will be used in
a computer match to check the income and resources I report with information from welfare, state employment, income tax, Social Security Administration, and
other agencies.
I understand that Sections 215, 9202, and 9203 of the Probate Code and Section 14009.5 of the Welfare and Institutions Code provide for the recovery of all
Medi-Cal benefits received after age 55 from the estate of a Medi-Cal beneficiary if there is no surviving spouse, minor children, or blind or totally disabled
children, or it would create a hardship for my heirs. After the death of my surviving spouse, the State has the right to claim from the part of his/her estate
received from me, all Medi-Cal benefits I received after age 55 up to the amount of property my spouse received from my estate.
I understand that I may be asked to prove my statements, but that the county is required by law to keep them confidential.
I understand that if I am dissatisfied with any action or inaction taken by the county welfare department, I have the right to a state hearing which I may request
from the county welfare department within 90 days after the action or inaction with which I am dissatisfied.
I realize that if I deliberately make false statements or withhold information, I (or the person on whose behalf I am acting) may lose my (or his/her) Medi-Cal
card and/or be prosecuted for fraud.
Signature of beneficiary Date
Signature of person acting for beneficiary Date
Signature of witness (if beneficiary signed with mark) Date
E.W. signature Date
MC 262 (06/07) Page 3 of 4
Yes
No
Yes
No
Yes No
Yes
No
Monthly
Quarterly Yearly
Yes
Yes
No
Yes
No
PRIVACY STATEMENT
O
Medi-Cal Confidentiality Notice: The information given in this application is private and confidential under
Welfare and Institutions Code, Section 14100.2. This information will be disclosed only in accordance with those
laws.
O
Medi-Cal Privacy Notice: This information may be shared with federal, state, and local agencies for purposes
of verifying eligibility and for other purposes related to the administration of the Medi-Cal program, including
confirmation with the INS of the immigration status of only those persons seeking full scope Medi-Cal benefits.
(Federal law says the INS cannot use the information for anything else except cases of fraud.)
O
Information required by this form is mandatory, with the exception of ethnicity information, and any other item
marked voluntary or optional.
MC 262 (06/07) Page 4 of 4
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Completed 30 July 2020

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