How to Submit Medical Redetermination Form

Contact your Medi-Cal clerk at your local Department of Public Social Services (DPSS) office to find out what you need to do to keep your Medi-Cal benefits. For more information, including contact information, see the letter you received. MC 220 8pt (06/08) – Permission to share information Alt: Spanish You can submit your renewal file using one of the following options. NOTE: You will not lose any benefits if you do not submit the kit while the COVID-19 public health emergency remains in effect: Medi-Cal members must renew their coverage each year to receive their health services. Some members may be renewed automatically, but a package is sent to members each year if the county is not able to verify all of your information. The forms for this package must be completed and returned. Members may return their information by mail, fax or telephone (for MAGI only) or they may forward it to their local district human service organization. For most members, coverage is automatically extended. Sometimes the county will send you an extension form that you need to review and return, along with any additional information required.

Your Medi-Cal coverage should be renewed annually. We will attempt to automatically renew your coverage by electronically verifying existing information. If we are unable to verify your information, we will send you a renewal form to complete and submit. If you do not renew your Medi-Cal, you will be unsubscribed from L.A. Care. You will need to resubmit your application to re-register. Please follow the instructions on the form and return it to DPSS as soon as possible. This ensures that you don`t lose your coverage. MC 214 (05/07) – Important Residency Information Old: Spanish All presumed eligibility forms for pregnant women are now available on our provider`s website for the following forms: MC 222 LA (02/14) – DDSD Awaiting Information Update (Los Angeles) MC 239 DRA-6 (02/10) – Information Notice – Unable to Verify United States (US) Citizenship/Identity by Social Security Administration Ancient: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese You have up to 90 days after the end of your Medi-Cal benefits to comply with your renewal. After 90 days, you will need to submit a new Medi-Cal application.

Please refer to the message you received, the date must be included in the entire message. After reviewing your information, we will send you a notification to confirm your renewal and notify you of any changes. Once you have completed and returned the form, the county will send you a letter informing you if you are still eligible for coverage. Medi-Cal Eligibility Division (MCED) forms are listed alphabetically below by form number and may include other languages if available. PDF filling and printing forms can be completed online and printed in paper form to be signed and sent by mail or in person to an authorized employee for processing. MC 224 B-S (05/07) – Potential Overpayment Report Supplementary Worksheet Medi-cal – Ineligibility or Total Ineligibility of Property for a Specific Level of Service MC 221 LA (02/14) – Determination and Transmission of Disability (Los Angeles) MC 278 TB (05/07) – Tb (TB) Program Property Worksheet Adult Online via MyBenefits CalWIN or Covered California MC 263-SR, MC 264, MC 265, MC 266, MC 267, MC 283, MC 285, & MC 286 MC 210 S-W (05/07) – Professional and Professional History Old: Spanish MC 210 PS (05/07) – Property Supplement Old: Chinese, Hmong, Russian, Spanish Medi-Cal members must renew their coverage each year to maintain their health services. . MC 212 (05/07) – Medi-Cal Declaration of Residence (Eng/Sp). L.A.

Care answers many questions from members about medi-Cal coverage renewal. For questions you have that are not covered, please call the Los Angeles County Department of Public Social Services (DPSS) number on the right. You will lose your Eligibility for Medi-Cal if you do not return your renewal plan and may need to reapply for Medi-Cal. MC 210 PA (05/07) – Property Assessment Statement of Facts Alt: Spanish MC 224 A (06/07) – Medi-Cal Potential Overpayment Report Worksheet Income or Other Health Coverage. MC 262 (06/07) – Redefinition for Medi-Cal beneficiaries (long-term care in their own MFBU) Old: Spanish. You can contact the SDSP at 1-866-613-3777 or 1-626-569-1399 (TTY: 1-800-660-4026). DPSS is open from Monday to Friday, except on public holidays from 7:30 am.m to 5:30 pm.m. . MC 210 A (09/07) – Supplement to the presentation of facts for retroactive report/restoration Old: Spanish.

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