Form MC05 "Military Verification and Referral Form - Ada Version" - California

What Is Form MC05?

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, 2016;
  • 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;
  • Fill out the form in our online filing application.

Download a fillable version of Form MC05 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 MC05 "Military Verification and Referral Form - Ada Version" - California

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State of California
Department of Health Care Services
Health and Human Services Agency
MILITARY VERIFICATION AND REFERRAL FORM
SECTION A: TO BE COMPLETED BY MEDI-CAL ELIGIBILITY WORKERS
1. NAME AND ADDRESS OF MEDI-CAL ELIGIBILITY
3. CASE WORKER NAME:
WORKER’S OFFICE:
4. WORKER PHONE #:
5. WORKER EMAIL:
2. NAME AND ADDRESS OF COUNTY VETERANS
6. CASE NUMBER:
SERVICE OFFICE:
7. MEDI-CAL AID CODE OF VETERAN OR
FAMILY MEMBER: (Required*)
VETERAN INFORMATION
8. VETERAN NAME
9. DATE OF
10. SOCIAL
11. VETERAN MARITAL
BIRTH (DOB):
SECURITY
STATUS (Mark only ONE):
(FIRST, MIDDLE, LAST):
NUMBER
(SSN):
SINGLE
MARRIED
DIVORCED
WIDOWED
UNKNOWN
12. VETERAN ADDRESS: (NUMBER, 13. VETERAN
14. VA INCOME 15. MILITARY
STREET, CITY, STATE, ZIP)
CONTACT
REPORTED (if
BACKGROUND
INFO:
applicable):
(Dates/Branch of Service):
$
VETERAN’S FAMILY INFORMATION
16. NAME:
17. RELATIONSHIP 18. DATE
19. SOCIAL
20. ADDRESS:
TO VETERAN:
OF BIRTH:
SECURITY
NUMBER:
21. MEDI-CAL WORKER REMARKS:
MC 05 (ADA 02/2016)
State of California
Department of Health Care Services
Health and Human Services Agency
MILITARY VERIFICATION AND REFERRAL FORM
SECTION A: TO BE COMPLETED BY MEDI-CAL ELIGIBILITY WORKERS
1. NAME AND ADDRESS OF MEDI-CAL ELIGIBILITY
3. CASE WORKER NAME:
WORKER’S OFFICE:
4. WORKER PHONE #:
5. WORKER EMAIL:
2. NAME AND ADDRESS OF COUNTY VETERANS
6. CASE NUMBER:
SERVICE OFFICE:
7. MEDI-CAL AID CODE OF VETERAN OR
FAMILY MEMBER: (Required*)
VETERAN INFORMATION
8. VETERAN NAME
9. DATE OF
10. SOCIAL
11. VETERAN MARITAL
BIRTH (DOB):
SECURITY
STATUS (Mark only ONE):
(FIRST, MIDDLE, LAST):
NUMBER
(SSN):
SINGLE
MARRIED
DIVORCED
WIDOWED
UNKNOWN
12. VETERAN ADDRESS: (NUMBER, 13. VETERAN
14. VA INCOME 15. MILITARY
STREET, CITY, STATE, ZIP)
CONTACT
REPORTED (if
BACKGROUND
INFO:
applicable):
(Dates/Branch of Service):
$
VETERAN’S FAMILY INFORMATION
16. NAME:
17. RELATIONSHIP 18. DATE
19. SOCIAL
20. ADDRESS:
TO VETERAN:
OF BIRTH:
SECURITY
NUMBER:
21. MEDI-CAL WORKER REMARKS:
MC 05 (ADA 02/2016)
State of California
Department of Health Care Services
Health and Human Services Agency
SECTION B: TO BE COMPLETED BY COUNTY VETERANS SERVICE OFFICE (CVSO)
3. TYPE OF ACTION (Mark ALL that apply) :
1. DATE:
2. VETERAN, SPOUSE,
CONTACTED/VERIFIED:
OR DEPENDENT/CHILD?
(Mark only ONE)
VA HEALTH ENROLLMENT
VA MONETARY BENEFIT
VETERAN
VA BENEFIT ENHANCEMENT
(ev
en if claim is under review/in process)
SPOUSE
DEPENDENT/CHILD
NOT ELIGIBLE
4. VA HEALTH ENROLLMENT TYPE (PLEASE SPECIFY IF APPLICABLE):
5. TYPE OF VA MONETARY
6. GROSS
7. IF
8. IS THIS
9. IF
BENEFITS (Mark ALL that
PAY:
A&A/SMC/SMP
PERSON LIVING IN APPLICABLE,
apply):
IS INCLUDED:
LONG TERM CARE DATE
$
(LTC)?
ENROLLED IN
(Mark only ONE)
LTC:
COMPENSATION
A&A: $
PENSION
SMC: $
PENSION RESTORED
SMP: $
YES
NO
AWARDED INCOME
SPECIAL COMPENSATION
OTHER:
10. CVSO REPRESENTATIVE REMARKS:
11. CVSO REPRESENTATIVE: (PRINT)
12. PHONE #:
13. DATE:
Privacy Statement: This referral is for individuals applying or receiving Medi-Cal benefits through the
Department of Health Care Services (DHCS). The personal and medical information provided on it is
private and confidential. DHCS or CWD will use this information to identify the applicant/recipient in order
to administer our programs. This information will be shared with other state, federal, and local agencies,
contractors, health plans, and programs only to enroll an applicant in a plan or program or to administer
programs, and with other state and federal agencies as required by law. In most cases, an applicant has
the right to see personal information about them that is in federal and state records. For the Department
of Health Care Services, contact the Information Protection Unit at: P.O. Box 997413, MS 4721
Sacramento, CA 95899-7413. Phone: 1-866-866-0602 TTY: 1-877-735-2929. State and federal laws give
us the right to collect and keep the information on the application: DHCS: CA Welfare and Institutions
Code § 14011 and Article 3, Chapters 5 and 7, Parts 2 and 3, Division 9. This Privacy Statement is given
under CA Civil Code §1798.17. DHCS's Notice of Privacy Practices can be seen at dhcs.ca.gov.
MC 05 (ADA 02/2016)
State of California
Department of Health Care Services
Health and Human Services Agency
M ILITARY VERIFICATION AND REFERRAL FORM INSTRUCTIONS
USE THE MILITARY VERIFICATION AND REFERRAL FORM:
To verify monetary amounts of veterans’ benefits and VA health enrollment for new applicants, curren
t
1.
Medi-Cal recipients, and during Medi-Cal redeterminations.
2. To refer applicants or recipients to the County Veterans Service Office (CVSO).
To obtain or enhance veteran benefits when the information on the Statement of Facts indicate a
3. m ilitary background.
* Do not complete this form if the service person is still on active duty.
INSTRUCTIONS FOR COMPLETION OF THE MEDI-CAL MILITARY REFERRAL FORM:
SECTION A: TO BE COMPLETED BY MEDI-CAL ELIGIBILITY WORKERS
# 1
Enter name and address of Medi-Cal eligibility worker’s office the form will be returned to.
# 2
Enter name and address of County Veterans Service Office (CVSO) the form will be sent to.
# 3-5
Enter case worker (person filling out the form) contact information on # 3 – 5.
# 6
Enter Medi-Cal case number of applicant/recipient (if applicable)
Enter valid Medi-Cal Aid Code. (Required)
* If necessary, county staff may enter the case’s anticipated aid code even though eligibility has
# 7
not yet been established. When the aid code is determined, county staff will update the aid code
(if different from the anticipated aid code) and inform CVSO of the updated aid code.
Enter all known personal information of Veteran. Required: Date of Birth (DOB), and Social
# 8-13
Security Number (SSN).
Enter the VA income reported by the applicant/recipient (if applicable). Verify and evaluate
# 14
income when MC 05 is returned.
Enter Veteran’s Military Background. This may include but not limited to Dates of Service/Branch
# 15
of Service etc.
Enter all family member information if someone other than the veteran is applying for benefits.
(E.g. Spouse or dependent/child of veteran.)
# 16-20
Note: A dependent is defined as a veteran whose parent(s)/ or family member who are
dependent upon him/her for financial support may be paid additional benefits from the VA based
on specific eligibility requirements.
Enter any additional notes/remarks that the CVSO may need to know regarding the Medi-Cal
# 21
applicant/recipient’s case that may help determine VA and Medi-Cal eligibility.
SECTION B: TO BE COMPLETED BY COUNTY VETERANS SERVICE OFFICE (CVSO)
Enter date you attempted to contact or verify the beneficiary and confirm whether they are the
veteran, spouse, or dependent/child.
# 1-2
* Military dependents are the spouse(s), children, and possibly other familial relationship
categories of a sponsoring military member (such as dependent parent of a veteran) for
purposes of pay as well as special benefits, privileges and rights.
# 3
Select VA benefit type the applicant is receiving and/or eligible to receive. Mark all that apply.
Enter VA Health Information. Specify if applicable.
# 4
This may include the VA Health System, CHAMPVA, TRICARE, or any other military health
coverage.
Select the type of monetary benefit the veteran is already receiving and/or entitled to receive
# 5
(Mark all that apply if applicable).
MC 05 (ADA 02/2016)
State of California
Department of Health Care Services
Health and Human Services Agency
# 6
Enter gross pay the veteran is reported to be receiving.
Enter amount of Aid and Attendance (A&A)/ Special Monthly Compensation (SMC)/ Special
# 7
Monthly Pension (SMP) if applicable. (A&A/SMC/SMP is required in order for the Medi-Cal
worker to properly treat income.)
# 8 - 9
If the veteran is in Long Term Care (LTC), enter all known LTC information (if applicable)
If applicable, enter any additional information/comments/remarks that may be necessary for the
# 10
Medi-Cal eligibility worker to know for eligibility determination.
#11- 13 Enter all CVSO contact information and date.
DISTRIBUTION AND FILING OF THE MEDI-CAL MILITARY VERIFICATION AND REFERRAL FORM:
1. The Medi-Cal eligibility worker will fill out Section A of the MC 05 form if a Medi-Cal
applicant/beneficiary or anyone in the household indicates they have a military background.
2. The Medi-Cal eligibility worker will keep one copy of the MC 05 for their records and submit the
original copy to the CVSO. The copy for the case file is to be retained until the original is completed
and returned by CVSO.
3. The CVSO will utilize any VA resources and/or contact the veteran and confirm VA benefits eligibility
(if any) and complete Section B of the MC 05 Form. This may include VA compensation, Health, and
enhancement of current benefits.
4. The CVSO will make a copy of the completed MC 05 form and keep it for case file records. The CVSO
will then return the original MC 05 form to the Medi-Cal eligibility worker.
5. The Medi-Cal eligibility worker will review the MC 05 form to complete/determine Medi-Cal eligibility.
Any incomes reported should be evaluated and have the Share of Cost (SOC) adjusted, if applicable.
If the applicant/recipient is in receipt/eligible for VA Health, the applicant must accept any
unconditionally available income for which they appear eligible followed by § 50186 of Title 22 of the
California Code of Regulations. For existing Medi-Cal recipients, The Medi-Cal worker will send the
recipient an MC 215 for voluntary discontinuance.
MC 05 (ADA 02/2016)