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

What Is Form MC604 IPS?

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 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 "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.
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:
Page 1 of 7
MC 604 IPS (5/14)
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.
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:
Page 1 of 7
MC 604 IPS (5/14)
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.
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.
Page 2 of 7
MC 604 IPS (5/14)
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 below.
SECTION 1
1. Cash or uncashed checks
Yes
No
If Yes list amount here $
2. Checking account or savings account
Yes
No
If Yes, send copies of account statements showing current balances.
3. Do you or a member of your household own more than one vehicle (cars, motorcycles, trucks)?
Yes
No
4. Do you or a member of your household 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.
5. Please review the list of property below.
Check this box if any member of your household owns or is named in 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 (where money or property is held for the benefit of any family member in
the home), judgments, settlement agreements, orders for support, prenuptial or postnuptial agreements, promissory
notes, mortgages or deeds of trust, business accounts, business property, oil and mineral rights, jewelry worth more
than $100.00 (but not wedding rings, engagement rings, or heirlooms), any other real or personal property, asset, or
resource worth $500 or more.
If you DID check the box, please go to SECTION 2 (below).
If you did NOT check this box, go to SECTION 3 on page 6.
SECTION 2
If you checked the box in Number 5 above, please complete this section and answer ALL questions. Please provide
written documentation with this form for any of the categories below to which you answer Yes. Examples of documents
include: policies, contracts, trusts, purchase agreements, court orders, settlement agreements, financial statements,
business tax returns, invoices, receipts, licenses, profit-and-loss statements, or other documents showing ownership or
other legal interest.
6. Shares of Stock or Mutual Funds
If Yes, please send a copy of the statements, or stock or mutual fund certificates showing the
number of shares
Yes
No
Page 3 of 7
MC 604 IPS (5/14)
7. Individual Retirement Accounts (IRAs), Keoghs, Work-Related Pension Funds or retirement
accounts, such as 401k or 457 accounts.
Yes
No
If Yes, please send the most recent statements from your employer, financial institution, or
brokerage showing the amount of principal and interest you are receiving or the cash value
of the account (after penalties for early withdrawal).
8. Annuities or Life Insurance
Yes
No
9. Burial Plots, Trusts, Burial Contracts or Burial Insurance
Yes
No
10. Trusts, blocked accounts or agreements (where money or property is held for the benefit of
any family member in the home)
Yes
No
11. Judgments, settlement agreements, orders for support, prenuptial or postnuptial agreements
Yes
No
12. Promissory notes, mortgages, or deeds of trust
Yes
No
If you answered Yes to any of the questions 6 through 12 (above), please provide copies
of policies, contracts, trusts, purchase agreements, court orders, settlement agreements,
or account documents showing payments, current market values, cash surrender values,
balances, investments, and distributions.
13. Jewelry worth more than $100.00 (but not wedding rings, engagement rings, or heirlooms).
Yes
No
If Yes, please send copies of sales receipts, appraisals, estimates of value or insurance documents.
14. Business Accounts and Property
Yes
No
If Yes, please send tax returns, invoices, receipts, licenses, profit-and-loss statements, or other
documents showing ownership, income and/or expenses.
15. Do you currently own a house, condominium, multiple dwelling unit, ranch, land, mobile
home, or life estate (right to the use of ) in the property which is currently or was previously
your home?
Yes
No
If Yes, do you live in the property now?
If Yes, write please write the address of the property here and go to question 16.
If you do not currently live in the property, did you live in it and do you hope to use it as your
home someday in the future?
Yes
No
If you answered Yes, go to question 16.
Page 4 of 7
MC 604 IPS (5/14)
If you answered No, does one or more of your family members, listed below, currently live
in that property?
Your spouse
A child under 21
A disabled son or daughter
A dependent relative who is a tax dependent
A sibling who also owns the property and who has lived there for at least a year before
you went into a nursing home
Another family member who has lived on the property for at least two years with you
to care for you so that you could stay home immediately before you went into a nursing
home
Yes
No
If you answered Yes, go to question 16.
If you answered No, please send a copy of the most recent tax assessment, or an appraisal
from a qualified real estate appraiser. We will use the lowest property value.
16. Other real estate that you own but don’t live in (e.g., condominiums, buildings, mobile homes,
life estates, time-shares)
Yes
No
If Yes, is any of the real estate producing income?
If Yes, please send copies of any rent receipts and bills for utilities, property taxes, insurance,
maintenance and repairs.
17. Oil and Mineral Rights
Yes
No
If you answered Yes to questions 15, 16 or 17, please send copies of the mortgage papers, most
recent tax assessment, registration, and ownership documents.
18. Any other real or personal property, asset, or resource worth $500 or more.
Yes
No
If Yes, please send statements about the property and its worth.
19. Have any of the items listed above in questions 2 through 18 been used to help finance or to
guarantee payment for medical services?
Yes
No
If Yes, please explain in the “Additional comments or information section” at the end of this
form, and attach proof of the lien, loan or security documents.
Yes
No
20. Do you owe money on anything listed above in questions 2 through 18?
Yes
No
If Yes, please send copies of the lien, loan, or security documents.
21. Certified California Partnership for Long-Term Care Insurance Policy
Yes
No
If Yes, please send a copy of your policy. If you have received benefits under the policy,
please send a copy of your most recent benefit statement.
Page 5 of 7
MC 604 IPS (5/14)
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