Form MC222 LA "Ddsd Pending Information Update" - California

What Is Form MC222 LA?

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 February 1, 2014;
  • 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 printable version of Form MC222 LA 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 MC222 LA "Ddsd Pending Information Update" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
DDSD PENDING
COUNTY WELFARE DEPARTMENT ADDRESS
INFORMATION UPDATE
DDSD ADDRESS
County Number
Aid Code
Case Number
DDSD-Los Angeles State Programs
Social Security Number
on MC 221
P.O. Box 992
El Segundo, CA 90245-0992
Applicant’s Name
(Last, First, MI)
Date of Birth
THIS FORM M UST BE USED WHEN A DIS ABILIT Y PACKET IS PENDING AT DDSD AND
CHANGED/ADDITIONAL INFORMATION NEEDS TO BE SUBMITTED TO DDSD (DO NOT USE MC 221 TO
REPORT CHANGES OR TO UPDATE INFORMATION.).
Check the appropriate box or boxes and complete the information.
1.
CHANGE OF ADDRESS
New address:
2.
CHANGE OF TELEPHONE NUMBER
New telephone number: (
)
3.
CHANGE OF SOCIAL SECURITY NUMBER
Corrected number:
4.
CASE CLOSED
Date:
(Discontinue evaluation)
5.
CLIENT DECEASED
Death certificate attached
Yes
No
6.
NON-ENGLISH SPEAKING
Language spoken:
Interpreter name:
Phone number: (
)
7.
UPDATED MEDICAL RECORDS ATTACHED
8.
CHANGE OF COUNTY WORKER (See below)
9.
OTHER
Worker name (Please print)
Worker number
Date
Telephone number
(
)
MC 222 LA (02/14)
State of California—Health and Human Services Agency
Department of Health Care Services
DDSD PENDING
COUNTY WELFARE DEPARTMENT ADDRESS
INFORMATION UPDATE
DDSD ADDRESS
County Number
Aid Code
Case Number
DDSD-Los Angeles State Programs
Social Security Number
on MC 221
P.O. Box 992
El Segundo, CA 90245-0992
Applicant’s Name
(Last, First, MI)
Date of Birth
THIS FORM M UST BE USED WHEN A DIS ABILIT Y PACKET IS PENDING AT DDSD AND
CHANGED/ADDITIONAL INFORMATION NEEDS TO BE SUBMITTED TO DDSD (DO NOT USE MC 221 TO
REPORT CHANGES OR TO UPDATE INFORMATION.).
Check the appropriate box or boxes and complete the information.
1.
CHANGE OF ADDRESS
New address:
2.
CHANGE OF TELEPHONE NUMBER
New telephone number: (
)
3.
CHANGE OF SOCIAL SECURITY NUMBER
Corrected number:
4.
CASE CLOSED
Date:
(Discontinue evaluation)
5.
CLIENT DECEASED
Death certificate attached
Yes
No
6.
NON-ENGLISH SPEAKING
Language spoken:
Interpreter name:
Phone number: (
)
7.
UPDATED MEDICAL RECORDS ATTACHED
8.
CHANGE OF COUNTY WORKER (See below)
9.
OTHER
Worker name (Please print)
Worker number
Date
Telephone number
(
)
MC 222 LA (02/14)