Forms
Human Services Agency
| Form | Description |
|---|---|
| SAWS 1 | |
| DHCS 7022 | Hospital Presumptive Eligibility (HPE): 1 page form that let's the client gain access to Emergency Medi-Cal(or RestrictedMedi-Cal if they are undocumented) through hospital processing immediately. |
| SAWS 2 Plus | Actual application form for Medi-Cal. Out of county transfers need to be done using the printed form. |
| MC 210 A (Formerly MC 213) - Supplement to Statement ofFacts for Retroactive Coverage/Restoration | Allows for thecoverage of healthcare costs going 3 months back from the date of Medi-Cal application. |
| MC 13 - Statement of Citizenship, Alienage, and ImmigrationStatus | Prucol (Permanent Residence under Color of Law) alien, undocumented individuals, individuals for expired visas to receive Restricted or Full Medi-Cal benefits. |
| Voter Registration Form | |
| General Affidavit Form | For any information that client is verbally telling but has no way of proving. |
| HCR RFTHI - Request for Tax Hold Info | Needed for income verification. Whoever is in the household is recorded. |
| HA 1708 - Medi-Cal Medical Report of Mental Incompetency or Incapacity | This form is used when the patient passed away, has no family member to sign for the patient, or the patient is not able to have the enrollment conversation (amnesia, mental health issues, not conscious, etc.) HA Team provides the form, but social worker or doctor fills it. Client gets referred to county. |
| DHCS 7068 - Responsibilities of Public Guardians/Conservators or applicant/Beneficiary Representatives | When a family member signs on behalf of client |
| Hospital Presumptive Eligibility Medi-Cal Application | Eligibility workers at the hospital to collect client information for Hospital Presumptive Eligibility (HPE)application. HPE gives patients temporary, no cost Medi-Cal coverage for up to 60 days. |
| Personal Financial Inventory (PFI) Form | |
| Statement of Facts for | |
| Retroactive Coverage/Restoration | Allows for the coverage of healthcare costs going 3 months back from the date of Medi-Cal application. |
| Universal Method for Determining Ability to Pay (UMDAP) | |
| MC 330 | |
Behavioral Health Access Center
| Form | Description |
|---|---|
| SAWS 1 | |
| DHCS 7022 | Hospital Presumptive Eligibility (HPE): 1 page form that let's the client gain access to Emergency Medi-Cal(or RestrictedMedi-Cal if they are undocumented) through hospital processing immediately. |
| SAWS 2 Plus | Actual application form for Medi-Cal. Out of county transfers need to be done using the printed form. |
| MC 210 A (Formerly MC 213) - Supplement to Statement ofFacts for Retroactive Coverage/Restoration | Allows for thecoverage of healthcare costs going 3 months back from the date of Medi-Cal application. |
| MC 13 - Statement of Citizenship, Alienage, and ImmigrationStatus | Prucol (Permanent Residence under Color of Law) alien, undocumented individuals, individuals for expired visas to receive Restricted or Full Medi-Cal benefits. |
| Voter Registration Form | |
| General Affidavit Form | For any information that client is verbally telling but has no way of proving. |
| HCR RFTHI - Request for Tax Hold Info | Needed for income verification. Whoever is in the household is recorded. |
| HA 1708 - Medi-Cal Medical Report of Mental Incompetency or Incapacity | This form is used when the patient passed away, has no family member to sign for the patient, or the patient is not able to have the enrollment conversation (amnesia, mental health issues, not conscious, etc.) HA Team provides the form, but social worker or doctor fills it. Client gets referred to county. |
| DHCS 7068 - Responsibilities of Public Guardians/Conservators or applicant/Beneficiary Representatives | When a family member signs on behalf of client |
| Hospital Presumptive Eligibility Medi-Cal Application | Eligibility workers at the hospital to collect client information for Hospital Presumptive Eligibility (HPE)application. HPE gives patients temporary, no cost Medi-Cal coverage for up to 60 days. |
| Personal Financial Inventory (PFI) Form | |
| Statement of Facts for | |
| Retroactive Coverage/Restoration | Allows for the coverage of healthcare costs going 3 months back from the date of Medi-Cal application. |
| Universal Method for Determining Ability to Pay (UMDAP) | |
| MC 330 | |
San Francisco General Hospital
| Form | Description |
|---|---|
| MC 210 A (Formerly MC 213) - Supplement to Statement ofFacts for Retroactive Coverage/Restoration | Allows for thecoverage of healthcare costs going 3 months back from the date of Medi-Cal application. |
| MC 13 - Statement of Citizenship, Alienage, and ImmigrationStatus | Prucol (Permanent Residence under Color of Law) alien, undocumented individuals, individuals for expired visas to receive Restricted or Full Medi-Cal benefits. |
| Voter Registration Form | |
| General Affidavit Form | For any information that client is verbally telling but has no way of proving. |
| HCR RFTHI - Request for Tax Hold Info | Needed for income verification. Whoever is in the household is recorded. |
| HA 1708 - Medi-Cal Medical Report of Mental Incompetency or Incapacity | This form is used when the patient passed away, has no family member to sign for the patient, or the patient is not able to have the enrollment conversation (amnesia, mental health issues, not conscious, etc.) HA Team provides the form, but social worker or doctor fills it. Client gets referred to county. |
| DHCS 7068 - Responsibilities of Public Guardians/Conservators or applicant/Beneficiary Representatives | When a family member signs on behalf of client |
| Hospital Presumptive Eligibility Medi-Cal Application | Eligibility workers at the hospital to collect client information for Hospital Presumptive Eligibility (HPE)application. HPE gives patients temporary, no cost Medi-Cal coverage for up to 60 days. |
| Statement of Facts for | |
| Retroactive Coverage/Restoration | Allows for the coverage of healthcare costs going 3 months back from the date of Medi-Cal application. |
| Universal Method for Determining Ability to Pay (UMDAP) | |
Navigation Centers
| Form | Description |
|---|---|