Form MC364 "California Department of Aging (Cda) Waiver Referral" - California

What Is Form MC364?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2007;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MC364 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form MC364 "California Department of Aging (Cda) Waiver Referral" - California

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Department of Health Care Services
State of California—Health and Human Services Agency
Medi-Cal Program
CALIFORNIA DEPARTMENT OF AGING (CDA)
COUNTY USE ONLY
Case name
Case number
WAIVER REFERRAL
Worker name
Worker number
Multipurpose Senior Services Program (MSSP) site: Please complete this portion and forward to the
appropriate County Waiver contact person.
Name of applicant
Address (number, street)
City
State
ZIP code
Social security number
Date of birth
Telephone
(
)
Guardian (if applicable)
Address of guardian (if different)
(number
, street)
City
State
ZIP code
Status
New Medi-Cal applicant.
Currently receives Medi-Cal with a share-of-cost.
Living Arrangement
The applicant is currently in an institution. Please determine Medi-Cal eligibility based on his/her
anticipated return to the community. Anticipated date of discharge:
The applicant is currently living in the home.
Other:
Eligibility Determination
If applicant/beneficiary is living or will live at home with his/her spouse and is property eligible and
entitled to zero share-of-cost Medi-Cal under regular eligibility rules, spousal impoverishment rules
are not utilized. If the applicant/beneficiary is property ineligible or has a share-of-cost, apply spousal
impoverishment income and resource rules (i.e., institutional deeming rules) even if the
applicant/beneficiary lives in the home. See Article 19D of the Medi-Cal Eligibility Procedures
Manual.
This is to certify that the individual named above has met the admission criteria for a nursing facility
as defined in the California Code of Regulations, Title 2, Division 3, Subdivision 1, Chapter 3,
Article 4, Sections 51334 and 51335.
Signature of MSSP site contact person
Printed name of MSSP site contact person
Title
Telephone
(
)
MSSP site address (number, street)
City
State
ZIP code
NOTE TO COUNTY: Please send a copy of the Notice of Action to the MSSP site when the determination is completed.
White: County Copy
Yellow: MSSP Site Copy
MC 364 (05/07)
Department of Health Care Services
State of California—Health and Human Services Agency
Medi-Cal Program
CALIFORNIA DEPARTMENT OF AGING (CDA)
COUNTY USE ONLY
Case name
Case number
WAIVER REFERRAL
Worker name
Worker number
Multipurpose Senior Services Program (MSSP) site: Please complete this portion and forward to the
appropriate County Waiver contact person.
Name of applicant
Address (number, street)
City
State
ZIP code
Social security number
Date of birth
Telephone
(
)
Guardian (if applicable)
Address of guardian (if different)
(number
, street)
City
State
ZIP code
Status
New Medi-Cal applicant.
Currently receives Medi-Cal with a share-of-cost.
Living Arrangement
The applicant is currently in an institution. Please determine Medi-Cal eligibility based on his/her
anticipated return to the community. Anticipated date of discharge:
The applicant is currently living in the home.
Other:
Eligibility Determination
If applicant/beneficiary is living or will live at home with his/her spouse and is property eligible and
entitled to zero share-of-cost Medi-Cal under regular eligibility rules, spousal impoverishment rules
are not utilized. If the applicant/beneficiary is property ineligible or has a share-of-cost, apply spousal
impoverishment income and resource rules (i.e., institutional deeming rules) even if the
applicant/beneficiary lives in the home. See Article 19D of the Medi-Cal Eligibility Procedures
Manual.
This is to certify that the individual named above has met the admission criteria for a nursing facility
as defined in the California Code of Regulations, Title 2, Division 3, Subdivision 1, Chapter 3,
Article 4, Sections 51334 and 51335.
Signature of MSSP site contact person
Printed name of MSSP site contact person
Title
Telephone
(
)
MSSP site address (number, street)
City
State
ZIP code
NOTE TO COUNTY: Please send a copy of the Notice of Action to the MSSP site when the determination is completed.
White: County Copy
Yellow: MSSP Site Copy
MC 364 (05/07)