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Get Ca Mc 171 2007-2025
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How to fill out the CA MC 171 online
The CA MC 171 form is essential for notifying the Department of Health Care Services about admissions and discharges to Medi-Cal long-term care facilities. This guide provides clear, step-by-step instructions on filling out the form online, ensuring a smooth process for all users.
Follow the steps to complete the CA MC 171 form online effectively.
- Click the ‘Get Form’ button to obtain the CA MC 171 form and open it in your chosen editing platform.
- In the first section, fill in the patient's name (last, first, middle initial) and their Social Security number. Enter the facility's name and the address (number and street, city, state, ZIP code). Ensure you check the box if the level of care is board and care.
- For admissions, provide the Medi-Cal ID number from the Medi-Cal card and the admission date in the format (month/day/year). Indicate whether the patient has Medicare Part A by selecting 'Yes' or 'No'.
- Specify the expected length of stay by selecting either 'At least one full month after the month of admission' or 'Less than one full month after the month of admission'. Select the appropriate option that describes the patient's prior admission, if applicable.
- Indicate whether Medi-Cal is expected to cover more than 50% of the facility's cost. If yes, specify the month when coverage begins.
- Fill out the current income section by checking all applicable boxes, and if the patient is moving from an acute hospital, enter the address prior to that admission.
- Obtain the necessary signatures from the recipient, representative payee, or family member. Make sure to fill in phone numbers and any reason for lacking the recipient’s signature.
- For discharges, provide the reason for discharge, the discharge date, and the Medi-Cal ID number. Enter the forwarding address if applicable.
- Finally, save your changes, then download, print, or share the completed form as necessary.
Complete your Medi-Cal documents online today.
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