Get Request For Withdrawal Waiver Of Ten Day Advance Notice Form

This guide provides a clear and comprehensive walkthrough for users to fill out the Request For Withdrawal Waiver Of Ten Day Advance Notice Form online. This form is essential for individuals seeking to withdraw their Medi-Cal application or request a waiver of the ten-day notice requirement.

Follow the steps to complete the form successfully.

1. Click the ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by filling in the case name, case number, worker number, and telephone number in the designated fields for county use only.
3. Select whether you are withdrawing a Medi-Cal application or discontinuing Medi-Cal eligibility by checking the appropriate box.
4. For application withdrawal, enter your name, the date of your application, and a brief explanation for the withdrawal in the provided space.
5. If requesting discontinuance, write your name, the desired effective date of discontinuance, and the reason for discontinuing your eligibility.
6. If choosing the beneficiary waiver option, fill in your name and the effective date, then indicate whether your eligibility or share-of-cost is impacted.
7. Acknowledge your understanding of the ten-day notice waiver by signing in the designated area and entering the date of your signature.
8. Review all the information entered for accuracy and completeness, then save the changes, download, print, or share the form as needed.

Complete your documents online today for a streamlined experience.