Form MC360 R "Medi-Cal Intercounty Transfer Packet Receipt" - California

What Is Form MC360 R?

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;

Download a fillable version of Form MC360 R 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 MC360 R "Medi-Cal Intercounty Transfer Packet Receipt" - California

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Department of Health Care Services
State of California—Health and Human Services Agency
MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT
TO:
_______________________________________________________________________
(Receiving County)
FROM: _______________________________________________________________________
(Sending County)
SENDING COUNTY:
Complete this information a
nd attach to the ICT packet.
Enclose a self-addressed return envelope.
Case name: ____________________________________________________________________
SSN and/or CIN: ________________________________________________________________
Worker name/worker code: ________________________________________
/
______________
Worker phone number (including area code): __________________________________________
E-mail address: _________________________________________________________________
RECEIVING COUNTY:
Complete this information.
Use the enclosed envelope to return to Sending County when the ICT packet has
been received/assigned.
ICT packet was received on
.
It has been assigned to:
(date)
Worker name/worker code: ________________________________________
/
______________
Worker phone number (including area code): __________________________________________
E-mail address: _________________________________________________________________
MC 360 R (05/07)
Department of Health Care Services
State of California—Health and Human Services Agency
MEDI-CAL INTERCOUNTY TRANSFER PACKET RECEIPT
TO:
_______________________________________________________________________
(Receiving County)
FROM: _______________________________________________________________________
(Sending County)
SENDING COUNTY:
Complete this information a
nd attach to the ICT packet.
Enclose a self-addressed return envelope.
Case name: ____________________________________________________________________
SSN and/or CIN: ________________________________________________________________
Worker name/worker code: ________________________________________
/
______________
Worker phone number (including area code): __________________________________________
E-mail address: _________________________________________________________________
RECEIVING COUNTY:
Complete this information.
Use the enclosed envelope to return to Sending County when the ICT packet has
been received/assigned.
ICT packet was received on
.
It has been assigned to:
(date)
Worker name/worker code: ________________________________________
/
______________
Worker phone number (including area code): __________________________________________
E-mail address: _________________________________________________________________
MC 360 R (05/07)