Form MC604 IPS AF "Additional Income and Property Information Needed for Medi-Cal" - California

What Is Form MC604 IPS AF?

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

Download a printable version of Form MC604 IPS AF 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 MC604 IPS AF "Additional Income and Property Information Needed for Medi-Cal" - California

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State of California Health and Human Services Agency
Department of Health Care Services
AdditionAl income And ProPerty informAtion
needed for medi-cAl
We are still evaluating your Medi-Cal eligibility and need
some additional information. Please answer the questions
below for everyone who is part of your household. This
includes you, your spouse, and children under 21 who
live with you or anyone who is temporarily absent from
your household, such as attending school or work or is
hospitalized.
case name:
case number:
Worker’s name:
Worker’s Phone number:
date Sent:
return this form By:
Additional Household Information Needed
The following additional information is needed.
Answer only if the questions on this page apply to you
or a member of your household.
MC 604 IPS AF (5/14)
Page 1 of 14
State of California Health and Human Services Agency
Department of Health Care Services
AdditionAl income And ProPerty informAtion
needed for medi-cAl
We are still evaluating your Medi-Cal eligibility and need
some additional information. Please answer the questions
below for everyone who is part of your household. This
includes you, your spouse, and children under 21 who
live with you or anyone who is temporarily absent from
your household, such as attending school or work or is
hospitalized.
case name:
case number:
Worker’s name:
Worker’s Phone number:
date Sent:
return this form By:
Additional Household Information Needed
The following additional information is needed.
Answer only if the questions on this page apply to you
or a member of your household.
MC 604 IPS AF (5/14)
Page 1 of 14
Please check here if you, or a member of your household, are
legally married but currently living apart from the spouse.
If you checked the box, please list the name of the person
in your household who is living apart from his or her
spouse.
Please check here if you or a member of the household is
a step-parent.
If you checked this box, please list:
The name of the Step-parent:
This Step-parent’s children:
Please check here if a member of the household is a child
who is being cared for by a relative, other than a parent,
who also lives in the household.
If you checked this box, please list:
The name of the Caretaker Relative:
The children being cared for:
MC 604 IPS AF (5/14)
Page 2 of 14
Tell Us About Your Income And Expenses
Tell us about your income and expenses for you, your spouse
and any of your children under 21 years of age who are living
in the home, or are temporarily absent from the home for
reasons such as attending school or work or is hospitalized.
Income
Please check Yes or No if anyone in your household receives
the type of income listed below.
Check a box for each income type.
Disability Benefits
Yes
No
Veteran’s Benefits
Yes
No
Child Support
Yes
No
Gifts
Yes
No
If you answered Yes to any of the above, please send proof
of that income with this form. Examples of documents
that can be used include: letters or statements from the
Social Security Administration, Veteran’s Administration,
Employment Development Department, court orders for
child support, or other written documents that have specific
information about the income.
MC 604 IPS AF (5/14)
Page 3 of 14
Expenses
Please check Yes or No if anyone in your household may be
paying the type of expense listed below.
Check a box for each expense type.
Child Support Paid
Yes
No
Other Health Premiums
Yes
No
Medicare Premiums
Yes
No
Childcare Expenses
Yes
No
Adult Care Expenses
Yes
No
Educational Expenses
Yes
No
If you answered Yes to any of the above, please send proof
of that expense with this form. Examples of documents that
can be used include: court orders for child support, tuition
statements, statements from Medicare or insurance company,
invoices or receipts of payment, or other written documents
that have specific information about the expense.
Tell Us About Your Property And Possessions
Please check Yes or No if anyone in your household has or
owns this type of property.
A box must be checked for each item 1, 2 and 3.
MC 604 IPS AF (5/14)
Page 4 of 14
Section 1
Cash or uncashed checks
Yes
No
1.
If Yes list amount here $
Checking account or savings account
Yes
No
2.
If Yes, send copies of account statements
showing current balances.
Do you or a member of your household
3.
own more than one vehicle (cars,
motorcycles, trucks)?
Yes
No
Do you or a member of your household
4.
own boats, recreational vehicles or trailers?
Yes
No
If you answered Yes to question 3 or 4,
please send copies of the ownership
documents or most recent registrations,
purchase agreements, sales receipts, or
estimates of value.
Please review the list of property below.
5.
Check this box if any member of your household owns
or is named on one or more of the following items.
Real estate other than the home you live in (houses,
condominiums, buildings, mobile homes, life estates,
time-shares), shares of stock, mutual funds, Individual
Retirement Accounts (IRAs), Keoghs, or work-related
pension funds, trusts, blocked accounts or agreements
MC 604 IPS AF (5/14)
Page 5 of 14
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