Get Ca Dhcs Mc 14a 2014-2026

The CA DHCS MC 14A form is used to apply for the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI-1) programs in California. This guide will walk you through the steps needed to complete the form effectively and accurately online.

Follow the steps to fill out the CA DHCS MC 14A online.

1. Click ‘Get Form’ button to access the CA DHCS MC 14A application form and open it in your document management tool.
2. Fill in your name, Social Security number, and Medicare number in the corresponding fields at the top of the form.
3. Enter your date of birth and contact information, including your telephone number, to ensure the authorities can reach you if needed.
4. Specify your gender and marital status by checking the appropriate boxes provided.
5. Provide your complete address including number, street, city, state, and zip code.
6. Indicate whether you would like to apply for retroactive coverage for SLMB and QI-1 programs by selecting 'Yes' or 'No'.
7. List all persons living in your household, including their names, Social Security numbers, dates of birth, and relationships to you.
8. Fill out the section regarding countable income. Input monthly income sources, including Social Security, VA benefits, retirement income, and any other unearned income.
9. Complete the property section, detailing the value of your checking and savings accounts, stocks, and other relevant assets.
10. After filling out all required fields, review the form for accuracy. Ensure all necessary information is complete before proceeding.
11. Once the form is complete, you can save your changes, download a copy, print it, or share it as needed.

Complete your CA DHCS MC 14A application online today to ensure your eligibility for essential Medicare programs.