Form MC 194 Social Security Administration Referral Notice - California

Form MC194 is a California Department of Health Care Services form also known as the "Social Security Administration Referral Notice". The latest edition of the form was released in July 1, 2012 and is available for digital filing.

Download an up-to-date fillable Form MC194 in PDF-format down below or look it up on the California Department of Health Care Services Forms website.

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State of California – Health and Human Services Agency
Department of Health Care Services
SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE
Instructions:
To CWD:
Please complete Part I. Retain original for your records, copy for recipient/SSA. Client must take this form to SSA.
To Recipients: Read the back of this form. Take the necessary documentation to the Social Security Administration listed below in Part I B.
• To SSA:
This form is a request for the action noted in Part I C. Please complete Part II of this form and distribute as noted in Part I A.
If you have any questions, the eligibility worker’s name and phone number are provided.
PART I: TO BE COMPLETED BY THE COUNTY WELFARE DEPARTMENT
A.
Please enter the complete county welfare office name and address within the brackets provided.
SSA, after completion:
FAX To:
Mail this form to the county welfare office.
Return this form to the recipient to be returned to CWD.
B. Social Security Office Information
C. If the bearer of this form is either an applicant or a recipient of Food
Stamps, Cash Aid, or Medi-Cal, the following service is required:
Name of SSA District/Regional Office
Original SSN card
Address (number and street)
Duplicate SSN card
SSN#:
Info on SSA’s Data Bases (Numident, Title II, Title XVI, and
City
State
ZIP Code
Medicare) needs to be verified.
Name
DOB
Sex
D. Applicant/Recipient Information
Info on SSA’s Data Bases (Numident, Title II, Title XVI, and
Recipient’s name (last, first, middle initial)
Medicare) needs to be corrected.
Name
DOB
Sex
Date of birth (month/day/year)
Sex (M or F)
Note: Recipient must provide verification of change.
Recipient has been assigned two SSNs. Please take action to
County ID per MEDS
delete all but one.
Two recipients appear to have been assigned the same SSN.
Recipient’s SSN (if applicable)
Case name
Please verify correct number for recipient from Numident File.
E. CWO Information
F. Comments
Name of Eligibility Worker
Date form completed
E.W. Worker
E.W. phone number
PART II: TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION DISTRICT/REGIONAL OFFICE
A. Date Received
B. Result of Referral
Recipient has completed an SSN application (including Form
SS-5 and other proof) and application is being processed.
C. Comments
Insufficient Identification
SSN application is not being processed. (Explain)
Other (Explain in Comments Section.)
D. SSA Representative – print name
Signature
Telephone Number
MC 194 (07/12)
State of California – Health and Human Services Agency
Department of Health Care Services
SOCIAL SECURITY ADMINISTRATION REFERRAL NOTICE
Instructions:
To CWD:
Please complete Part I. Retain original for your records, copy for recipient/SSA. Client must take this form to SSA.
To Recipients: Read the back of this form. Take the necessary documentation to the Social Security Administration listed below in Part I B.
• To SSA:
This form is a request for the action noted in Part I C. Please complete Part II of this form and distribute as noted in Part I A.
If you have any questions, the eligibility worker’s name and phone number are provided.
PART I: TO BE COMPLETED BY THE COUNTY WELFARE DEPARTMENT
A.
Please enter the complete county welfare office name and address within the brackets provided.
SSA, after completion:
FAX To:
Mail this form to the county welfare office.
Return this form to the recipient to be returned to CWD.
B. Social Security Office Information
C. If the bearer of this form is either an applicant or a recipient of Food
Stamps, Cash Aid, or Medi-Cal, the following service is required:
Name of SSA District/Regional Office
Original SSN card
Address (number and street)
Duplicate SSN card
SSN#:
Info on SSA’s Data Bases (Numident, Title II, Title XVI, and
City
State
ZIP Code
Medicare) needs to be verified.
Name
DOB
Sex
D. Applicant/Recipient Information
Info on SSA’s Data Bases (Numident, Title II, Title XVI, and
Recipient’s name (last, first, middle initial)
Medicare) needs to be corrected.
Name
DOB
Sex
Date of birth (month/day/year)
Sex (M or F)
Note: Recipient must provide verification of change.
Recipient has been assigned two SSNs. Please take action to
County ID per MEDS
delete all but one.
Two recipients appear to have been assigned the same SSN.
Recipient’s SSN (if applicable)
Case name
Please verify correct number for recipient from Numident File.
E. CWO Information
F. Comments
Name of Eligibility Worker
Date form completed
E.W. Worker
E.W. phone number
PART II: TO BE COMPLETED BY THE SOCIAL SECURITY ADMINISTRATION DISTRICT/REGIONAL OFFICE
A. Date Received
B. Result of Referral
Recipient has completed an SSN application (including Form
SS-5 and other proof) and application is being processed.
C. Comments
Insufficient Identification
SSN application is not being processed. (Explain)
Other (Explain in Comments Section.)
D. SSA Representative – print name
Signature
Telephone Number
MC 194 (07/12)
SSA REFERRAL INFORMATION SHEET
(For Medi-Cal, Food Stamp, and CalWORKs Recipients)
YOU MUST CONTACT SOCIAL SECURITY
Public Law requires that each person who applies for or receives full-scope Medi-Cal, Food Stamps, or
California Work Opportunity and Responsibility to Kids must have or apply for a social security number.
For the applicant/ recipient noted on the reverse side, either (1) the Social Security Administration does
not have a social security number on file, or (2) the information provided by the Social Security
Administration and the information provided to the eligibility worker do not agree. To correct this situation,
you must contact the Social Security Office indicated on the reverse side of this referral form. DO NOT
MAIL THESE FORMS TO THEM.
NOTE: Age, citizenship or alien status, and identity must all be documented. One of the identification
documents must be a birth or baptismal certificate established BEFORE age 5. If one is not
obtainable, refer to Column A for acceptable substitutes. In addition, if the applicant/recipient is
a U.S. citizen born outside of the U.S. or an alien, one of the items listed in Column B must be
presented.
Column A
Column B
1. Evidence of Age/Citizenship
1. If you are now a U.S. citizen born outside the
U.S., take one of the following items in
• School records
addition to the item(s) required in Column A:
• Church records
• U.S. citizen identity card
• Census records (state or federal)
• U.S. passport
• Insurance policy
• Naturalization certificate
• Marriage records
• Certificate of citizenship
• Draft card
• Consular report of birth
• U.S. passport
• Form I-179 (U.S. citizen card)
• Other records indicating applicant’s age or
• Form I-197 (U.S. citizen resident card)
date and place of birth
2. If you are an alien, take one of the following
2. Evidence of Identity
items in addition to the item(s) listed in
Column A:
• Driver’s license
• State identification card
• Form I-151 or I-551 (Alien Registration
• Voter’s registration
Receipt Card)
• School records
• Form AR3a, I-94, I-95a, I-84, I-85, I-86, or
• Health records (doctor’s, hospital’s, etc.)
SW-434
• Any other document which shows
• Letters from Immigration and
applicant’s signature, photograph, or
Naturalization Service showing alien
description
status
If you have a question concerning the two identification documents which you must take to the Social
Security Office, please contact the Social Security Office.
MC 194 (07/12)

Download Form MC 194 Social Security Administration Referral Notice - California

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