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Get Request For Withdrawal Waiver Of Ten Day Advance Notice Form

State of California Health and Human Services Agency D epartment of Health Care Services Medi-Cal Program FOR COUNTY USE ONLY Case name Case number Worker number Telephone number REQUEST FOR WITHDRAWAL AND/OR WAIVER OF TEN-DAY ADVANCE NOTICE MEDI-CAL APPLICATION WITHDRAWAL I ask that my application for Medi-Cal dated. I understand that my Medi-Cal eligibility will not be determined at this time. I can reapply at any time. MEDI-CAL ELIGIBILITY DISCONTINUANCE effective // because BENEFICIARY WAIVER OF TEN-DAY NOTICE have reported effective // my Medi-Cal eligibility must be discontinued* my Medi-Cal share-of-cost must be increased* the above action must be taken based on the information I reported it is not necessary for the county to send me this notice within the ten-day limit* time. I understand that if I ask for a state hearing before the effective date of the action the county s action will be delayed* Signature of Applicant/Beneficiary MC 215 05/07 Date. I understand that my Medi-Cal eligibility will not be determined at this time. I can reapply at any time. MEDI-CAL ELIGIBILITY DISCONTINUANCE effective // because BENEFICIARY WAIVER OF TEN-DAY NOTICE have reported effective // my Medi-Cal eligibility must be discontinued* my Medi-Cal share-of-cost must be increased* the above action must be taken based on the information I reported it is not necessary for the county to send me this notice within the ten-day limit* time. MEDI-CAL ELIGIBILITY DISCONTINUANCE effective // because BENEFICIARY WAIVER OF TEN-DAY NOTICE have reported effective // my Medi-Cal eligibility must be discontinued* my Medi-Cal share-of-cost must be increased* the above action must be taken based on the information I reported it is not necessary for the county to send me this notice within the ten-day limit* time. I understand that if I ask for a state hearing before the effective date of the action the county s action will be delayed* Signature of Applicant/Beneficiary MC 215 05/07 Date. I understand that my Medi-Cal eligibility will not be determined at this time. I can reapply at any time. MEDI-CAL ELIGIBILITY DISCONTINUANCE effective // because BENEFICIARY WAIVER OF TEN-DAY NOTICE have reported effective // my Medi-Cal eligibility must be discontinued* my Medi-Cal share-of-cost must be increased* the above action must be taken based on the information I reported it is not necessary for the county to send me this notice within the ten-day limit* time. I understand that if I ask for a state hearing before the effective date of the action the county s action will be delayed* Signature of Applicant/Beneficiary MC 215 05/07 Date.

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Keywords relevant to Request For Withdrawal Waiver Of Ten Day Advance Notice Form

  • REAPPLY
  • Applicant
  • discontinued
  • waiver
  • beneficiary
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