MC 171 (05/07) MEDI-CAL LONG-TERM CARE FACILITY ADMISSION AND DISCHARGE NOTIFICATION. (Instructions and distribution on reverse.)

NF-As and NF-Bs are required to complete the Medi-Cal Long Term Care Facility Admission and Discharge Notification (MC 171) form on admission or discharge of a patient.

What is the phone number for Medi Cal long term care?

Automated Phone Center: 1-800-786-4346 The automated phone center is available 7 a.m. to 8 p.m., seven days a week.

What is the period of ineligibility for Medi-Cal?

The period of ineligibility is always the lesser of one of the following: - 30 months; or - the number of months obtained by dividing the value of the transfer by the APPR; or - the difference between 30 months from the date of the transfer and the date of application for Medi-Cal benefits, inclusive.

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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