Form MC604 MDV "Doctor's Verification for Home and Community Based Services Under Spousal Impoverishment Provisions" - California

What Is Form MC604 MDV?

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 August 1, 2017;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Cambodian;
  • 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 MDV 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 MDV "Doctor's Verification for Home and Community Based Services Under Spousal Impoverishment Provisions" - California

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(COUNTY LETTERHEAD)
Date:
PATIENT’S INFORMATION (County Completes This Section)
PATIENT NAME:
PATIENT DATE OF BIRTH:
CLIENT INDEX NUMBER (CIN):
Dear Dr.
Please complete and return the statement below to the county by
regarding your
patient listed above so that we can determine his\her eligibility for Medi-Cal. Please use the postage paid
pre-addressed envelope. You may also return it by fax or email as indicated below. Your patient has given
authorization to release this information to us. Please see attached patient authorization.
County Worker Signature:
Date:
County Worker Printed Name:
Phone Number:
Fax Number:
County Worker Email:
Doctor’s Verification for Home and Community Based Services Under Spousal Impoverishment Provisions
DOCTOR’S INFORMATION
DOCTOR’S PRINTED NAME:
DATE:
TELEPHONE:
EMAIL:
Based on my examination, my patient,
, will likely require nursing facility
level of care for at least 30 consecutive days unless he/she receives in-home care and support services that
will permit him/her to reside safely at home. My patient first began needing these services at a nursing
facility level of care on
, and has continued to need these services since that date.
I declare under penalty of perjury under the laws of the United States of America and the State of California
that the information contained in this Doctor’s Verification is true and correct.
DOCTOR’S SIGNATURE:
MC 604 MDV (08/17)
(COUNTY LETTERHEAD)
Date:
PATIENT’S INFORMATION (County Completes This Section)
PATIENT NAME:
PATIENT DATE OF BIRTH:
CLIENT INDEX NUMBER (CIN):
Dear Dr.
Please complete and return the statement below to the county by
regarding your
patient listed above so that we can determine his\her eligibility for Medi-Cal. Please use the postage paid
pre-addressed envelope. You may also return it by fax or email as indicated below. Your patient has given
authorization to release this information to us. Please see attached patient authorization.
County Worker Signature:
Date:
County Worker Printed Name:
Phone Number:
Fax Number:
County Worker Email:
Doctor’s Verification for Home and Community Based Services Under Spousal Impoverishment Provisions
DOCTOR’S INFORMATION
DOCTOR’S PRINTED NAME:
DATE:
TELEPHONE:
EMAIL:
Based on my examination, my patient,
, will likely require nursing facility
level of care for at least 30 consecutive days unless he/she receives in-home care and support services that
will permit him/her to reside safely at home. My patient first began needing these services at a nursing
facility level of care on
, and has continued to need these services since that date.
I declare under penalty of perjury under the laws of the United States of America and the State of California
that the information contained in this Doctor’s Verification is true and correct.
DOCTOR’S SIGNATURE:
MC 604 MDV (08/17)
(COUNTY LETTERHEAD)
Date:
Patient Authorization
I,
authorize doctor
to release the medical information on this form to
County for the
purpose of establishing my eligibility for Medi-Cal.
I authorize the use or disclosure of my individually identifiable health information as described above
for the purpose listed.
I have the right to withdraw permission for the release of my information. If I sign this authorization to
use or disclose information, I can revoke that authorization at any time. The revocation must be made in
writing and will not affect information that has already been used or disclosed.
I have the right to receive a copy of this authorization.
I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits
under this program may not be possible if I do not sign this authorization.
I further understand that a person to whom records and information are disclosed pursuant to this
authorization may not further use or disclose the medical information unless another authorization is
obtained from me or unless such disclosure is specifically required or permitted by law.
SIGNED:
DATE:
If not signed by the patient who is the subject of this disclosure, specify basis for authority to sign:
£ Parent of Minor
£ Guardian
£ Spouse
£ Authorized Representative
Explain relationship to the patient and why the patient is unable to sign:
WITNESS: I know the person signing this form or am satisfied of this person’s identity:
(Required for “X”, illegible, or foreign character signatures)
Witness signature:
Date:
Street Address:
City/Zip Code:
This general and special authorization to disclose information has been developed to comply with the provisions regarding
disclosure of medical and other information under: The Health Insurance Portability and Accountability Act, Section 262(a), 42
U.S.C, Section 1320d-1320d-8 (45 CFR Part 164); 42 U.S.C., Section 290dd-2 (42 CFR Part 2); 38 U.S.C., Section 7332; 20 U.S.C.,
Section 1232g (34 CFR Parts 99 and 300); and state law, including Civil Code, Section 56.10(b), Welfare and Institutions Code,
Section 10850 and 14100.2 and Civil Code, Sections 1798-1798.78.
MC 604 MDV (08/17)
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