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Get CA MC 171 2007-2023

Se.) I. COMPLETE THIS PORTION FOR ALL ACTIONS Patient’s name (last) (first) (MI) Name of facility Social security number Address (number and street) Note: City Level of care is SNF/ICF unless checked here as board and care. State ZIP code II. COMPLETE THIS PORTION ONLY FOR ADMISSIONS Medi-Cal ID number (taken from the Medi-Cal card) Admission date (month/day/year) A. Do you have Medicare Part A, Hospital Coverage? E. Admission from: Yes Home No Household of another B. Expect.

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