Form CW 103 Request for Extended or Transitional Medi-Cal - California

Form CW103 or the "Request For Extended Or Transitional Medi-cal" is a form issued by the California Department of Social Services.

The form was last revised in November 1, 2009 and is available for digital filing. Download an up-to-date fillable Form CW103 in PDF-format down below or look it up on the California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL MEDI-CAL
MEDI-CAL FOR WORKING PEOPLE
YOUR FAMILY MAY GET FREE HEALTH CARE!
Transitional Medi-Cal (TMC) is for California
families who are no longer eligible for CalWORKs
cash aid or Medi-Cal for low income families
because of earnings from work. All members of the
family may still get no-cost Medi-Cal for up to
12 months.
IMPORTANT FACTS ABOUT TMC AND OTHER KINDS OF HEALTH CARE COVERAGE
If you just got a job or just started to get more money from your job, but your cash aid or Medi-Cal was stopped for some
other reason, be sure to tell us about it. To tell your worker about the job or pay raise or self-employment and request
TMC, fill out and return the form on the back of this flyer to your county welfare department.
To get the first 6 months of TMC you must:
have been on CalWORKs cash aid or Medi-Cal for low income families, and
have a child in the home.
To get the rest of the months of TMC you must also:
continue to work, and
earn under a certain amount, and
report earnings quarterly.
After TMC coverage ends, the children may get other Medi-Cal or Healthy Families program coverage.
EXTENDED MEDI-CAL FOR FAMILIES GETTING CHILD SUPPORT
Four months of extended Medi-Cal may be available for families losing CalWORKs cash aid or Medi-Cal for low income
families due to increased child/spousal support. If you want this kind of Medi-Cal, we need to know about these
changes. Please complete the back of this form.
If you need help understanding this notice, contact your County worker.
Spanish
Chinese
Russian
Vietnamese
Cambodian
CW 103 (11/09) MULTILINGUAL - REQUIRED FORM - SUBSTITUTES PERMITTED
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
TRANSITIONAL MEDI-CAL
MEDI-CAL FOR WORKING PEOPLE
YOUR FAMILY MAY GET FREE HEALTH CARE!
Transitional Medi-Cal (TMC) is for California
families who are no longer eligible for CalWORKs
cash aid or Medi-Cal for low income families
because of earnings from work. All members of the
family may still get no-cost Medi-Cal for up to
12 months.
IMPORTANT FACTS ABOUT TMC AND OTHER KINDS OF HEALTH CARE COVERAGE
If you just got a job or just started to get more money from your job, but your cash aid or Medi-Cal was stopped for some
other reason, be sure to tell us about it. To tell your worker about the job or pay raise or self-employment and request
TMC, fill out and return the form on the back of this flyer to your county welfare department.
To get the first 6 months of TMC you must:
have been on CalWORKs cash aid or Medi-Cal for low income families, and
have a child in the home.
To get the rest of the months of TMC you must also:
continue to work, and
earn under a certain amount, and
report earnings quarterly.
After TMC coverage ends, the children may get other Medi-Cal or Healthy Families program coverage.
EXTENDED MEDI-CAL FOR FAMILIES GETTING CHILD SUPPORT
Four months of extended Medi-Cal may be available for families losing CalWORKs cash aid or Medi-Cal for low income
families due to increased child/spousal support. If you want this kind of Medi-Cal, we need to know about these
changes. Please complete the back of this form.
If you need help understanding this notice, contact your County worker.
Spanish
Chinese
Russian
Vietnamese
Cambodian
CW 103 (11/09) MULTILINGUAL - REQUIRED FORM - SUBSTITUTES PERMITTED
REQUEST FOR EXTENDED OR TRANSITIONAL MEDI-CAL
Did your Medi-Cal or CalWORKs cash aid stop and:
■ ■
■ ■
You have earnings from a job, a business you started, or a pay raise? . . . . . . . . . . . . . . .
YES
NO
■ ■
■ ■
You have started to receive or had an increase in child/spousal support payments? . . . . .
YES
NO
If you answered “YES” to any of these questions, you and other family members may still be eligible for Medi-Cal.
Complete this form and attach pay stubs or other proof of earnings. If you are self-employed, list business costs on a
separate sheet of paper and attach proof of income and costs.
Return this request form to:
If the information you give us is complete and we can tell from your case file that you qualify, we will put you and eligible
family members on an extended Medi-Cal program, such as the TMC program. If we need more information from you,
we will contact you.
I declare under penalty of perjury that all information provided is true and correct.
NAME
SOCIAL SECURITY NUMBER
SIGNATURE
TELEPHONE NUMBER
DATE
(
)
ADDRESS
CITY
ZIP CODE
SIGNATURE OF WITNESS, INTERPRETER, OR PERSON ASSISTING
TELEPHONE NUMBER
DATE
(
)
CW 103 (11/09) MULTILINGUAL - REQUIRED FORM - SUBSTITUTES PERMITTED

Download Form CW 103 Request for Extended or Transitional Medi-Cal - California

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