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Get Ca Mc 171 2007-2025

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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Related content

MC 171 (05/07) - Medi-Cal Long-Term Care Facility...
State of California—Health and Human Services Agency. Department of Health Care...
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California - CiteSeerX
California. Forms Catalog. July 2004. State and Federal. Computerized Legal Forms...
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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.

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

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.

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

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232