Form MC210 A "Supplement to Statement of Facts for Retroactive Coverage/Restoration" - California

What Is Form MC210 A?

This is a legal form that was released by the California Department of Social 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 September 1, 2007;
  • The latest edition provided by the California Department of Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form MC210 A by clicking the link below or browse more documents and templates provided by the California Department of Social Services.

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Download Form MC210 A "Supplement to Statement of Facts for Retroactive Coverage/Restoration" - California

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State of California—Health and Human Services Agency
Department of Health Care Services
Case Name _______________________________________________________________________
Case Number _________________________
SUPPLEMENT TO STATEMENT OF FACTS FOR RETROACTIVE COVERAGE/RESTORATION
My present circumstances, as listed on the Statement of Facts which I signed on ______________________, are true and correct statements,
(Date)
to the best of my knowledge, for the month(s) of ____________________________________________________ except as specified below.
(for restorations, this should be the month in which the request is made)
Circumstances that are/were different:
(If no change, write in “No change.”) Documentation is needed to verify all sources of income and
to support any difference in property, residence, etc.
Month:
Month:
Month:
Circumstances
Number of persons living in your home
Income—
Specify any differences in:
Amount of income
Kind of income
Work expenses
Education expenses
Child care
All Personal Property including motor
vehicles, boats, bank accounts, etc.
(Lowest bank account balances should
be listed for each month unless they
Checking:
Checking:
Checking:
were exactly the same as the balance
listed on the Statement of Facts. List
Savings:
Savings:
Savings:
differences or state “No change.”
Real Property (list differences only or
state “ No change.”)
!
!
!
!
!
!
California Resident
Yes
No
Yes
No
Yes
No
!
!
!
!
!
!
Other Insurance Coverage Change
Yes
No
Yes
No
Yes
No
Other (List differences only or state “No
change.”)
I understand that I may not retroactively spend my property down in order to reduce its amount and thereby qualify for Medi-Cal.
I understand that I may be asked to prove my statements but that the county is required by law to keep them confidential, and that if dissatisfied,
I have a right to a fair hearing. I understand that if I deliberately make false statements or withhold information, I can be prosecuted for fraud.
Signature
Date
Signature of person acting for applicant and relationship (guardian, conservator, etc.)
Date
Signature of witness (required if applicant signed by mark)
Date
The following person helped me to fill out this form:
Name and relationship to applicant
Address
Date
Page 1 of 3
MC 210 A (09/07) (Formerly MC 213)
State of California—Health and Human Services Agency
Department of Health Care Services
Case Name _______________________________________________________________________
Case Number _________________________
SUPPLEMENT TO STATEMENT OF FACTS FOR RETROACTIVE COVERAGE/RESTORATION
My present circumstances, as listed on the Statement of Facts which I signed on ______________________, are true and correct statements,
(Date)
to the best of my knowledge, for the month(s) of ____________________________________________________ except as specified below.
(for restorations, this should be the month in which the request is made)
Circumstances that are/were different:
(If no change, write in “No change.”) Documentation is needed to verify all sources of income and
to support any difference in property, residence, etc.
Month:
Month:
Month:
Circumstances
Number of persons living in your home
Income—
Specify any differences in:
Amount of income
Kind of income
Work expenses
Education expenses
Child care
All Personal Property including motor
vehicles, boats, bank accounts, etc.
(Lowest bank account balances should
be listed for each month unless they
Checking:
Checking:
Checking:
were exactly the same as the balance
listed on the Statement of Facts. List
Savings:
Savings:
Savings:
differences or state “No change.”
Real Property (list differences only or
state “ No change.”)
!
!
!
!
!
!
California Resident
Yes
No
Yes
No
Yes
No
!
!
!
!
!
!
Other Insurance Coverage Change
Yes
No
Yes
No
Yes
No
Other (List differences only or state “No
change.”)
I understand that I may not retroactively spend my property down in order to reduce its amount and thereby qualify for Medi-Cal.
I understand that I may be asked to prove my statements but that the county is required by law to keep them confidential, and that if dissatisfied,
I have a right to a fair hearing. I understand that if I deliberately make false statements or withhold information, I can be prosecuted for fraud.
Signature
Date
Signature of person acting for applicant and relationship (guardian, conservator, etc.)
Date
Signature of witness (required if applicant signed by mark)
Date
The following person helped me to fill out this form:
Name and relationship to applicant
Address
Date
Page 1 of 3
MC 210 A (09/07) (Formerly MC 213)
State of California—Health and Human Services Agency
Department of Health Care Services
SANDRA SHEWRY
ARNOLD SCHWARZENEGGER
Director
Governor
IF YOU WERE ELIGIBLE FOR MEDI-CAL ANYTIME SINCE JUNE 27, 1997, OR ARE ELIGIBLE NOW,
MEDI-CAL MAY REIMBURSE YOU FOR MEDICAL OR DENTAL BILLS YOU PAID
Conlan v. Bontá; Conlan v. Shewry
As the result of two court decisions, you may be able to be repaid for some medical expenses you paid. The Department of
Health Care Services (DHCS) will assist you in getting your money back if all criteria below are met:
1. You received a medically necessary medical or dental service during one or all of these time periods:
The 3-month period prior to the month you applied for the Medi-Cal program,
From the date you applied for the Medi-Cal program until the date your Medi-Cal card was issued,
After your Medi-Cal card was issued (includes excess co-payment and excess share of cost charges).
2. You paid for your medical or dental service; or another person paid for your medical or dental service on your behalf. You
will be asked to provide proof that the medical or dental service was paid for by you or the other person.
3. You received the medical or dental service from a Medi-Cal enrolled provider (note: you do not need to have received the
service from a Medi-Cal enrolled provider if you received the medical or dental service during the 3-month period prior to
applying to Medi-Cal, or you received the services on or after June 27, 1997 but before February 2, 2006 and you had
applied for Medi-Cal but not yet received a Medi-Cal card).
4. For those Medi-Cal services that were provided and would have required Medi-Cal authorization, you have documentation
from the medical or dental provider that shows medical necessity for the service.
5. You were Medi-Cal eligible to receive that specific medical or dental service.
6. The medical or dental service was a benefit under the Medi-Cal program.
7. The medical or dental service was provided on or after June 27, 1997.
8. After you received your Medi-Cal card, you contacted your provider and showed your provider your Medi-Cal card and the
provider would not give you your money back.
Important dates and time frames:
For services received June 27, 1997, through November 16, 2006, you must submit your claim by November 16, 2007, or
within 90 days after issuance of the Medi-Cal card, which ever is longer.
For services received on or after November 16, 2006, you must submit your claim within one year of receipt of services,
or within 90 days after issuance of the Medi-Cal card, which ever is longer.
For more information or to file a claim, you MUST call or write to Medi-Cal at:
For Medical, Mental Health, Drug and Alcohol, and
For Dental Claims:
In-Home Support Services Claims:
Department of Health Care Services
Denti-Cal
Beneficiary Services
Beneficiary Services
P.O. Box 138008
P.O. Box 526026
Sacramento, CA 95813-8008
Sacramento, CA 95852-6026
(916) 403-2007
TDD: (916) 635-6491
(916) 403-2007
TDD: (916) 635-6491
--DON’T FORGET TO KEEP ALL RECEIPTS FOR THE MEDICAL AND DENTAL CARE YOU RECEIVE --
Medi-Cal will review your claim for repayment and send you a letter with a check or a denial letter that tells you the reason for
denial. If Medi-Cal denies your request for payment, you may ask for a state hearing. The denial letter will tell you how to ask
for a state hearing.
Medicare/Medi-Cal Coverage: Starting January 1, 2006, medications covered under Medicare Part D will not be a covered
benefit under the Medi-Cal Program and are not eligible for reimbursement. For questions regarding Medicare Part D contact
1-800-Medicare.
MC 210 A (09/07)
Page 2 of 3
PRIVACY STATEMENT
Medi-Cal Confidentiality Notice: The information given in this application is private and confidential
under Welfare and Institutions Code, Section 14100.2. This information will be disclosed only in
accordance with those laws.
Medi-Cal Privacy Notice: This information may be shared with federal, state, and local agencies for
purposes of verifying eligibility and for other purposes related to the administration of the Medi-Cal
program, including confirmation with the INS of the immigration status of only those persons seeking full
scope Medi-Cal benefits. (Federal law says the INS cannot use the information for anything else except
cases of fraud.)
MC 210 A (09/07)
Page 3 of 3
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