Common-Place Handbook Intake/RRR Packets 24. … · signature packet and a packet of informational...

Common-Place Handbook page 24-1Intake/RRR Packets

24. Intake/RRR Packets

At application, each client applying for public assistance is given or mailed a signature packet and a packet of informational forms and other mandated materials which explain a particular facet of the program to the client. Many of these forms are mandated by the State, and EWs must insure that clients receive the correct information. A verbal explanation may also be necessary, if the client is unable to read. In addition there are also informational packets that will be covered later in this chapter.

24.1 Intake Signature Packet

24.1.1 Mail-In Applications

Effective July 1, 2000, the mandatory face-to-face interview requirement was eliminated for Medi-Cal only. The eligibility determination process has not changed with the elimination of the face-to-face interview at application. Each case record must contain adequate information with supportive documentation to verify eligibility.

24.1.2 Clerical Preparation

Signature packets of forms are prepared and distributed by the clerical staff in each District Office, depending upon the aid program for which the client applies.

24.1.3 Content

This section includes the mandatory forms which must be in the packet for each specific program. Social Services Program Managers (SSPMs) may choose to use additional forms which expedite the Intake process and/or provide information to the applicant.

The contents of the various packets differ based on whether the applicant will be doing a face-to-face interview or will be mailing in their application.

Update #16-29 Revised:12/15/16

page 24-2 Common-Place HandbookIntake/RRR Packets

Reminder:The Statement of Facts is done interactively in CalWIN when the client comes in for a face-to-face interview. However, for mail-in applications, the California Department of Social Services (CDSS) and California Department of Health Services (CDHS) application forms are used.

Note:The SAWS 1 is required when the client is unable to complete the SAWS 2 Plus or CF 285 on the application filing date.

24.1.4 CalWORKs/RCA, Medi-Cal and CalFresh

For CalWORKs/RCA, Medi-Cal and CalFresh combination applications, the following forms are given to the applicant in the Initial Contact Packet:

FORM # FORM NAME

EW Must Explain

AVAILABLE LANGUAGES

Eng. Sp. Viet. Other

SCD 41 Identification and Intake Record

No X X X

SAWS 1 Initial Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care Programs

No X X X

SAWS 2 Plus Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care

No X X X

SAWS 2A SAR

RIGHTS, RESPONSIBILITIES AND OTHER IMPORTANT INFORMATION

Yes X X X Arm., Chin., Russ.

CCP 7 CalWORKs Stage One Child Care Request Form & Payment Rules

No X X X

CSF 67 EBT Card and PIN Responsibility Statement

Yes X X

SCD 95 Paternity Affidavit Yes X X

SCD 103 Acknowledgement of Limited Sharing of Information

Yes X X X

Revised:12/15/16 Update #16-29


24.1.5 CalFresh

For CalFresh applications, the following forms are given to the applicant in the Initial Contact Packet:

FORM # FORM NAMEEW Must Explain

AVAILABLE LANGUAGES



No X X X 1

1. This form is not available in any other languages.

CF 285 Application for CalFresh Benefits

Yes X 2

2. Until translations are available, it is recommended that SAWS series of forms are used for the clients who elected to receive materials in languages other than English. If CF 285 is issued to a non-English speaking client, it must be accompanied with the GEN 1396-Notice of Language Services and a local contact number.


Yes X X

SCD 508 Would you like to Register to Vote?

No X X

SCD 1264 Language Survey-Interpreter/Translation Request


SCD 2300 Proof Needed No X X X

SCD 2304 Additional Information Notices

No X X


No X X


Yes X X X



No X X

FORM # FORM NAME

EW Must Explain

AVAILABLE LANGUAGES




24.1.6 Medi-Cal

For Medi-Cal applications, the following forms are given to the applicant in the initial contact packet:


AVAILABLE LANGUAGES



No X X X 1

1. This form is not available in any other language.

A Postage-Paid Pre-Addressed return envelope must be included with all mail-in applications.

CCFRM 604 Application for Health Insurance [(Also known as Single Streamline application (SSAApp)]

Yes X X X

SCD 115 (Families)

Consent to Exchange/ Release Information-CHI

Yes X X X X


No X X X Farsi, Kor., Lao., Camb., Chin., Hmong Tag., Russ., Jap.



SCD 93 (A, B, C, D)

Application Coverletter (Specific to District Office)

No X X X X


SCD 2304 Additional Information Notices No X X

SCD 2263 Consent to Release Public Assistance Information for Health Services Reimbursement

Yes X X X X

Note:



24.1.7 Medi-Cal and CalFresh

For Medi-Cal and CalFresh applications, the following forms are given to the applicant in the Initial Contact Packet:

FORM # FORM NAME

EW Must Explain

AVAILABLE LANGUAGES



No X X X 1



NOTE: Designated staff must complete.

No X X X

SAWS 2 Plus

Application for CalFresh, Cash Aid, And/Or Medi-Cal/Health Care Programs

Yes X X X

SAWS 2A SAR


Yes X X X


Yes X X

MC 003 EPSDT Flyer (if there are persons under 21)

No X X


No X X





No X X



24.1.8 CAPI and CalFresh

For CAPI and CalFresh applications, the following forms are given to the applicant in the Initial Contact Packet:

FORM # FORM NAME EW Must Explain

AVAILABLE LANGUAGES



No X X X 1


[Refer to CAPI Handbook, “Required Forms,” page 2-5 for complete list of CAPI Intake packet forms.]


No X X X

SAWS 2 Plus

Application for CalFresh, Cash Aid, and Medi-Cal/Health Care Programs

Yes X X X

SAWS 2A SAR


Yes X X X


Yes X X

SCD 508

Would you like to Register to Vote?

No X X

SCD 1264

Language Survey-Interpreter/Translation Request

Yes X X X

SCD 2300

Proof Needed No X X X

SCD 2300A

Proof Needed

SCD 2304

Additional Information Notices

No X X



24.1.9 GA and CalFresh

For General Assistance (GA) and CalFresh, the following forms are included in the Initial Contact Packet.


AVAILABLE LANGUAGES

Eng.Sp. Viet. Other


No X X X 1


SAWS 2 Plus

Application for CalFresh, Cash Aid, and Medi-Cal/Health Care Programs

Yes X X


Yes X X

SCD 103 The Acknowledgment of Limited Sharing of Information for the Administration of the Cash Aid Programs

Yes Yes No X X


No X X


Yes X X X

SCD 2300A

Proof Needed No X X X

SCD 2304 Additional Information Notices No X X

GA 1 Application for General Assistance

X X 1.

SSP 14 Authorization for Reimbursement of Interim Assistance Initial Claim or Post eligibility Case

X X X X Russ, Chin,



24.2 Informational Intake Packet

In addition to the Signature Packet there are many forms and mandated materials which must be provided to all clients. The following subsections list the forms that must be included in the informational packet specific to the program or programs for which the client is applying.

• Hard Copy means that the form is included in the packet.• Posted on the Web means that the form is available on the SSA Internet portal

for clients to view/download.

• CalWORKs http://www.sccgov.org/ssa/afdc_info_notices.html

• Medi-Cal http://www.sccgov.org/ssa/mc_info_notices.html

• CalFresh http://www.sccgov.org/ssa/fs_info_notices.html

24.2.1 CalWORKs and PA CalFresh

The Intake packet for CalWORKs and Public Assistance (PA) CalFresh includes the state mandated informing notices for CalWORKs applicants.

FORM # FORM NAMEHard Copy

Posted on the WEB

EW Must Explain

AVAILABLE LANGUAGES


CS 196 Child Support Enforcement Program Notice

No Yes No X X X Arm., Chin., Hmong, Russ.

CW 103 Transitional Medi-Cal

No Yes No X X X Chin., Camb.

CW 2184 CalWORKs 48-Month Time Limit

Yes No Yes X X X Chin., Russ.

CW2209 Immunization Good Cause Form

Yes No Yes X X X



CF 23 SAR or CF 23 CR

How to Report No Yes No X X Russ.

EBT 2216 EBT Surcharge Free - Direct Deposit Handout

Yes No Yes X

GEN 1365 Notice of Language Services

Yes No No X X X Multi- lingual

PUB 13 Your Rights Under California Welfare Programs

No Yes No X X X

PUB 160 Child Support Handbook

No Yes No X X X Camb., Chin.

PUB 183 Free Health Check-ups for Babies, Children, Youth (under 21)

No Yes No X X X

PUB 275 Family Planning... Making the Commitment to a Healthy Future

No Yes No X X X Camb., Chin., Hmong, Lao., Russ.

PUB 388 California EBT Card

Yes No No X X X

PUB 429 Earned Income Tax Credit

Yes No Yes X X X

PUB 910169

California Counties Grow Healthy with WIC

Yes No No X X X

SAR 3 Mid-Period Status Report

No Yes No X X X

SAR 7 Addendum

Instructions & Penalties Semi-Annual Eligibility/Status Report

No Yes Yes X X X

SAR 7A How to Fill Out Your SAR 7

Yes No Yes X X X Arm., Chin., Russ.


Posted on the WEB

EW Must Explain

AVAILABLE LANGUAGES




SCD 571 EBT Brochure No Yes No X X X 1

SCD 830 Important Notice about Domestic Abuse

Yes Yes No X X X Camb Bos., Russ.

SCD 833 CalWORKs Immunization Rules

Yes No Yes X X X Russ. Camb

SCD 1255 Important Notice to All Clients

Yes No No X X X

SCD 1500 Direct Deposit Program Brochure

No Yes No X X X Camb Russ. Bos., Chin.

SCD 2300 Proof Needed No Yes No X X X


Yes No No X X

SCD 2331C

Make the Most of Your Time in the CWES Program

Yes Yes Yes X X X

SCD 2341 My Benefits CalWIN

Yes Yes No X X

SCD 2382 Electronic Notification Option

Yes No No X X X

SCD 2402 SAR 7 Sample Yes No Yes X X X

WTW 5 Welfare to Work Informing Notice

Yes No Yes X X X Armenian, Camb Chinese, Korean,Lao. Russ.



Posted on the WEB

EW Must Explain

AVAILABLE LANGUAGES




24.2.2 CalFresh

The Intake packet for CalFresh contains the State mandated informing notices for CalFresh and for mail-in applications the forms which must be completed to determine eligibility for CalFresh.

Note:In addition to the following forms, all forms listed in “Informational Intake Packet,” page 24-8 must also be placed in this packet.


Posted on the WEB

EW Must Explain

AVAILABLE LANGUAGES

Eng. Sp. Viet Other


How to Report Household Changes

No Yes No X X Russ.

PUB 13 Your Rights Under California Welfare Programs

No Yes No X X X

PUB 275 Family Planning No Yes No

SAR 7A How to Fill Out Your SAR 7

Yes No Yes X X X Arm., Chin., Russ.

SCD 571 EBT Brochure No Yes No X X X

SCD 827 Citizenship Fact Sheet

No Yes No X X X 1


SCD 1504 READ ME -- NOTICE OF USE OF COMPUTER SYSTEMS

No Yes No X X X

SCD 2300 Proof Needed No Yes No X X X


Yes No No X X

SCD 2341 My Benefits CalWIN

Yes Yes No X X



24.2.3 Medi-Cal

The Intake Informational packet for Medi-Cal contains the State mandated informing notices for Medi-Cal and for mail-in applications the forms which must be completed to determine eligibility for Medi-Cal.

24.2.4 Medi-Cal Intake Informational Packet

The following forms are to be used in the Medi-Cal Intake Informational packet:


Posted on the WEB

EW Must Explain

AVAILABLE LANGUAGES


DHCS 7077

Notice Regarding Standards for Medi-Cal Eligibility

Yes Yes No X X

DHCS 7077A

Notice Regarding Transfer of a Home for both a Married and an Unmarried Applicant/ Beneficiary

Yes Yes No X X

MC 003 EPSDT Flyer Yes Yes No X X

MC 004 Important Information for Nursing Home Patients

No Yes No X X 1

MC 007 Medi-Cal General Property Limitations

Yes No No X X

MC 018 Medi-Cal Information for Applicants

No Yes No X X X Arm., Chin., Farsi, Hmong, Khmer, Korean, Lao., Russ.

MC 18 Important Notice About Your Medi-Cal Benefits

No Yes No X X 1



Note:A Postage-Paid Pre-Addressed return envelope must be included WITH all mail-in applications.

MC 219 Important Information for Persons Requesting Medi-Cal (Rights and Responsibilities)

Yes No No X X x Arm., Chin., Farsi, Hmong, Khmer, Korean, Lao., Russ.,

MC 325 Transitional Medi-Cal

Yes No No X

MC 372 Breast and Cervical Cancer Treatment Program

Yes No No X X

PUB13 Your rights Under CA Welfare Programs

Yes No No X X X

PUB 68 Medi-Cal - What it Means to You

Yes No No X X

PUB183 CHDP Brochure Yes No No X X X

SCD 391 Keep Your Medi-Cal on Target

No Yes No X X X

SCD 827 Citizenship Fact Sheet

No Yes No X X X


No Yes No X X X

SCD 2341

My Benefits CalWIN

Yes Yes No X X

WIC Brochure

Families Grow Healthy with WIC

Yes No No X X X Chin

Informing Notice of IRS Form 1095-B

Informing Notice of IRS Form 1095-B

No Yes No X X


Posted on the WEB

EW Must Explain

AVAILABLE LANGUAGES




24.2.5 General Assistance (GA)

The intake packet for GA includes the informing notices mandated for General Assistance and the forms which must be completed to determine GA eligibility. This also includes the forms for CalFresh.

FORM # FORM NAME

AVAILABLE LANGUAGES



X X X Arm., Chin, Lao., Russ.


How to Report Household Changes X X Russ.


X

GA 1 Application for GA X X

GA 2A Housing Verification - Specialized Programs

X

GA 11 Clients Housing Assistance Statement

X X X

GA 14 General Assistance - Rights and Responsibilities

X

GA 23 GA Program Resource Guide X X X

GA 26 General Assistance Bureau Vocational Services Department Participant Handbook

X X X

GA 31 Housing Assistance Verification X X X

GA 31L Important Information to Landlord Regarding General Assistance Vendor Payment

X X X

GA 61 Information Regarding GA Payments for Homeless Individuals

X X X

GA 62 General Assistance Information Sheet

X X X

GA 67 Appointment Notice for GA - Important - Do Not Lose This Form

X X X

GA 100 Statement of Facts for General Assistance

X

GA 475 Employment History X X X



PUB 388 California EBT Card X X X

QR 7A How to Fill Out Your QR7 Quarterly Eligibility/Status Report

X X X Camb., Chi., Russ., Hmong

SAR 7 A How to Fill Out Your SAR 7 X X X Arm., Chin., Russ.

1SAWS 2A SAR

Rights, Responsibilities and Other Important Information for Cash Aid, Food Stamps and Medical Assistance/CMSP

X X X Camb., Chin., Russ., Hmong

SCD 103 Acknowledgement of Limited Sharing of Information for the Administration of Cash Aid Programs

X X X Bos., Camb., Russ.

SCD 355 S/A

Agreement to Reimburse-Sponsor X X

SCD 508 Would you like to register to vote? X X X Farsi, Kor., Lao., Camb., Hmong, Tag., Russ., Jap.,

SCD 571 EBT Brochure X X X

SCD 1500 Direct Deposit Program Brochure X X X Camb., Chin., Russ., Bos.


X X

Temp 2214 Additional Information About EBT X X X Camb., Lao., Russ., Chin., Farsi, Hmong, Arm.

SCD 2300 Proof Needed X X X

SSP 14 Authorization for Reimbursement of Interim Assistance Initial Claim or Post eligibility Case

X X X Russ, Chin,

W-9 Request for Taxpayer Identification Number and Certification

X

1. The SAWS 2A SAR is used when the client completed the SAWS 1 and the CalWIN Statement of Facts (CSF 60) instead of CF 285.

FORM # FORM NAME

AVAILABLE LANGUAGES




24.2.6 Cash Assistance Program for Immigrants (CAPI)

The intake packet for CAPI includes the informing notices mandated for CAPI and the forms which must be completed to determine CAPI eligibility.

FORM # FORM NAME

AVAILABLE LANGUAGES



X X X Arm., Chin., Lao., Russ.d


X


SAWS 2 Plus

Statement of Facts for Medi-Cal (Used as Statement of Facts for CAPI)

Note: ONLY needed if applying for Food Stamps and/or Medi-Cal.

X X X Arm., Chin., Farsi, Hmong, Khmer, Korean, Lao., Russ.,

SAWS 1 Application For Cash Aid, Food Stamps, And/Or Medi-Cal/State CMSP

X X X

SCD 41 Identification and Intake Record X X X



SCD 122 CAPI - General Eligibility Information and Payment Levels

X X X Camb., Chin., Russ.


SCD 573 Cash Assistance Program for Immigrants


SCD 574 Important Information About Required Verification (CAPI)

SCD 575 CAPI - Important Notice X X X Camb., Chin., Russ., Bos.

SCD 576 CAPI Recipients are Required to Apply for Supplemental Security Income (SSI/SSP)

X X X Camb., Chin., Russ., Bos.

SCD 1264 Language Survey X X X



24.3 Foster Care Intake Packets

Intake packets are compiled by Triage at the Foster Care Bureau. Social Workers (SWs) and Probation Officers (POs) are responsible to complete and provide the required "Statement of Facts Supporting Eligibility for AFDC-FC" (FC2) and "Court Order" documents to the Triage unit.

There are five separate intake packets for Foster Care. The packets are separated into the following categories:

• Voluntary Placements or Legal Guardian Placements• Court Ordered Foster Care Placements• Medi-Cal Out-of-State (Foster Care ICPC and AAP ICAMA)• Adoption Assistance Program (AAP)• Kin-GAP.


SCD 2300A

Proof Needed X X X

SOC 453 CAPI Statement of Household Expenses and Contributions

X X X Chin., Russ.

SOC 814 Statement of Facts - CAPI X X X

SSP 14 Authorization For Reimbursement Of Interim Assistance Granted Pending SSI/SSP Eligibility Determination

X X X Russion, Chinese

Temp 2214 Additional Information About EBT X X X Camb., Lao., Russ., Chin., Farsi, Hmong, Arm.

FORM # FORM NAME

AVAILABLE LANGUAGES




24.3.1 Voluntary Placements or Legal Guardian Placements

The following application forms are used in Voluntary Placement Packets:

FORM # FORM NAME

AVAILABLE LANGUAGES


FC 2 Statement of Facts Supporting Eligibility for AFDC-FC

X X 1


SAWS 1 Application for Cash Aid, Food Stamps, and Medi-Cal Assistance

X X X Chin., Russ.

SAWS 2 Plus Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care

X X X Russ., Chin., Camb.

SAWS 2A SAR




SOC 155 Voluntary Placement Agreement X X X

24.3.2 Court Ordered Foster Care Placements

The following application forms are used for Foster Care Placement packets:

FORM # FORM NAME

AVAILABLE LANGUAGES


FC 2/ SAWS 2

Statement of Facts Supporting Eligibility for AFDC-FC

X X 1


X X X Chin., Russ.

SAWS 2A SAR







24.3.3 Kin-GAP

FORM # FORM NAME

AVAILABLE LANGUAGES


SOC 369 Agency Relative Guardianship Disclosure

X X X

SOC 369 (A)

Kinship Guardianship Assistance Payment (Kin-GAP) Program Agreement Amendment

X

SCD 21 Kin-GAP Information Sheet X

24.3.4 Medi-Cal Out-of-State (Foster Care and AAP)

The following application forms are used for Medi-Cal Out-of State Placement packets:

FORM # FORM NAME

AVAILABLE LANGUAGES


MC 250 Application and Statement of Facts for Child Not Living with a Parent or Relative and for Whom a Public Agency is Assuming Some Financial Responsibility

X 1



X X X Chin., Russ.





24.3.5 Adoption Assistance Program (AAP)

The following application forms are used for the Adoption Assistance Program intake packets:

FORM # FORM NAME

AVAILABLE LANGUAGES


AAP 2 Payment Instructions X

AAP 4 Eligibility Certification Adoption Assistance Program

X

FC 10 Income and Property Checklist for Federal Eligibility Determination - Adoption Assistance Program

X

24.4 Telephonic Signature Phone Interviews for CalWORKs or CalWORKs and/or CalFresh RD/RC

The telephonic RD/RC process eliminates the need to mail out the CalWORKs and CalFresh RD/RC packets to clients prior to the telephone interview.

After the TS interview process has been completed, the forms listed below (informational packet) are sent by Centralized Support Services (CSS) to the client along with a copy of the Statement of Facts, indicating any new or changed information provided by the client.

EWs must send clients who choose to have a Face to Face RRR instead of a TS telephone interview, the CalWORKs and CalFresh RRR Packet prior to their scheduled office interview date.



24.4.1 CalWORKs and PA CalFresh RRR Packet

The Redetermination (RRR) packet for CalWORKs and Public Assistance (PA) CalFresh includes the state mandated informing notices for CalWORKs recipients. Forms followed with an asterisk (*), should ONLY be sent to clients scheduled for Face to Face interviews.

FORM # FORM NAME

AVAILABLE LANGUAGES


CCP 7* CalWORKs Stage One Child Care Request Form and Payment Rules

X X


X X X Arm., Chin, Lao., Russ.d

CW 2.1 Q Support Questionnaire X X X

CW 2.1 NA CW 2.1 Child/Spousal and Medical Support Notice and Agreement

X X X

CW 80 Self-Certification Form For Motor Vehicles

X X X

CW 103 Transitional Medi-Cal X X X Chin., Camb.

CW 2184 CalWORKs 48 Month Time Limit X X


X

GEN 1365 Notice of Language Services X X X

PUB 13 Your Rights Under California Law X X X


X X X

PUB 275 Family Planning - Making the Commitment to a Healthy Future

X X X


PUB 429 Earned Income Tax Credit X X X

PUB 910168 Families Grow Healthy With WIC

X X X Chinese

SAR 7 Addendum

Instructions & Penalties Semi-Annual Eligibility/Status Report

X X X

SAR 7 A How to Fill Out Your SAR 7 X X X



* = These forms are reviewed by phone when a Telephonic Signature RRR is being completed and do NOT need to be included in the Informational Packet sent by CSS to the client. The signature line of these forms must indicate that the client(s) signed by TS and then be scanned into IDM.

SAWS 1* Initial Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care

X X X

SAWS 2 Plus* Application for CalFresh, Cash Aid, and/or Medi-Cal/Health Care

No X X X

SAWS 2A SAR*



SCD 103* The Acknowledgment of Limited Sharing of Information for the Administration of the Cash Aid Programs


SCD 508* Would you like to register to vote? X X X Farsi, Kor., Lao., Camb., Chin., Hmong, Tag., Russ., Jap.



X X X Camb., Bos., Russ.

SCD 833 CalWORKs Immunization Rules X X X Russ., Camb.

SCD 1255 Important Notice to All Clients X X X

SCD 1264* Language Survey (every 3 years) X X X

SCD 2304 Additional Information Notices X X

SCD 2331C WTW 24 Month Activities Information Notice

X X X

SCD 2341 My Benefits CalWIN X X

SCD 2382 Electronic Notification Option X X X

SCD 2402 Sample SAR 7 X X X

WTW 5 Welfare to Work Program Notice X X X

WIC Flyer WIC Outreach Flyer X

FORM # FORM NAME

AVAILABLE LANGUAGES




24.5 CalFresh RRR Packet

The Redetermination (RRR) packet for CalFresh contains the State mandated informing notices for CalFresh and for mail-in applications the forms which must be completed to determine eligibility for CalFresh.

24.5.1 Semi-Annual Reporting

The following forms are to be included in packets for Semi-Annual Reporting Households:

FORM # FORM NAME

AVAILABLE LANGUAGES

Eng. Sp. Viet Other

CF 2851 Application for CalFresh Benefits X

CF 23 SAR How to Report Household Changes

X X X Russ.



X X X

SAR 7A How to Fill Out Your SAR 7 X X X Arm., Chin., Russ.

SAR 7 Addendum

Instructions & Penalties Semi-Annual Eligibility/Status Report”

X X X

SCD 508** Would you like to register to vote? X X X Farsi, Kor., Lao., Camb., Hmong, Tag., Russ., Jap.,

SCD 1264** Language Survey - Interpreter/Translation Request

X X X Farsi, Kor., Lao., Camb., Hmong, Tag., Russ., Jap,

SCD 1504 Read Me -- Notice of Use of Computer Systems

X


SCD 2304 Additional Information Notice X X



** Benefits must not be interrupted if form is not received.

1. Until translations are available, it is recommended that SAWS series of forms are used for the clients who elected to receive materials in languages other than English. If CF 285 is issued to a non-English speaking client, it must be accompanied with the GEN 1396-Notice of Language Services and a local contact number.



24.6 Medi-Cal RD Packet

There are four separate Redetermination (RD) Packets for Medi-Cal (MC). Each packet includes state mandated informing notices for Medi-Cal recipients and the forms which must be completed to redetermine MC eligibility. The packets are separated into the following categories:

• MAGI MC RD,• Mixed MC RD, • Non-MAGI MC RD and• Long Term Care (LTC).

24.6.1 MAGI MC RD Packets

The following forms are to be used in the MAGI MC RD packet only:

FORM # FORM NAME

AVAILABLE LANGUAGES


GEN 1365 Notice of Language Services X X X Multilingual

MC 216 Medi-Cal Renewal Form X X X

PUB 183 CHDP Flyer X X X

MC 003 EPSDT Flyer X X

MC 019 Medi-Cal Information for Beneficiaries



X X x Arm., Chin., Farsi, Hmong, Khmer, Korean, Lao., Russ.,

MC 372 Breast and Cervical Cancer Treatment Program (BCCTP)

X X

Pub 13 Your Rights Under California Welfare Program

X X X



24.6.2 Mixed MC RD Packets

The following forms are to be used in the Mixed MC RD packet only

SCD 115 Consent to Exchange/Release Information-CHI

X X X Bos., Camb., Chin., Korean, Port., Russ., Samoli, Tag.

SCD 508 National Voter Registration Interest Form

X X X


X X X


SCD 2365 Second Harvest Food Bank & CalFresh Outreach Flyer

X X X

SCD 2382 Electronic Notification Option X X

SCD 2439 Medi-Cal Redetermination Contact Flyer

X X X

WIC 2 WIC Outreach Flyer X X X

FORM # FORM NAME

AVAILABLE LANGUAGES



MC 216 Medi-Cal Renewal Form X X X

MC 604 IPS Evaluation for Non-MAGI MC X X X





FORM # FORM NAME

AVAILABLE LANGUAGES




24.6.3 Non-MAGI Medi-Cal RD Packet

The following forms are to be used in the Non-MAGI MC RD packet only:




X X


X X X




X X X


X X X



X X X



X X X


FORM # FORM NAME

AVAILABLE LANGUAGES



FORM # FORM NAME

AVAILABLE LANGUAGES




MC 210 RV Notice Medi-Cal Redetermination Informing Notice

X X X Chinese,Arm. Korean, Russ. Tagalog, Cambodian, Hmong,

MC 210 RV Medi-Cal Annual Redetermination Form

X X X *Chinese,Arm. Korean, Russ. Tagalog, Cambodian, Hmong,





MC 210 PS Property Supplement X X




X X


X X X




X X X


X X X



X X X

FORM # FORM NAME

AVAILABLE LANGUAGES




24.6.4 Medi-Cal Packets - Long Term Care (LTC)

The following forms are to be used in Long Term Care (LTC) Medi-Cal RRR packets only:



X X X


FORM # FORM NAME

AVAILABLE LANGUAGES



MC 210 RV Notice Medi-Cal Redetermination Informing Notice

X X X Chinese, Arm. Korean, Russ. Tagalog, Cambodian, Hmong

MC 262 (LTC) Redetermination for Medi-Cal beneficiaries (LTC)

X X X

MC 004 Nursing Home Patient Information

X



MC 18 Important Notice about your MC Benefits

X X

MC 210 PS Property Supplement X X



Pub 13 Your Rights Under California Welfare Programs

X X X

FORM # FORM NAME

AVAILABLE LANGUAGES




24.7 General Assistance (GA) RRR Packet

The Redetermination (RRR) packet for GA includes the mandate informing and the forms which must be completed to determine GA eligibility. This also includes the forms for CalFresh.

DHCS 7068 Responsibilities of Public Guardian/ conservators or Applicant/ Beneficiary Representatives

X X


X X


X X X




X X X

FORM # FORM NAME

AVAILABLE LANGUAGES



How to Report Household Changes X X X Arm., Chin., Russ.


X

GA 14 General Assistance - Rights and Responsibilities

X

GA 61 Information Regarding GA Payments for Homeless Individuals

X X X

GA 100 Statement of Facts for General Assistance

X

FORM # FORM NAME

AVAILABLE LANGUAGES




QR 7A How to Fill Out Your QR 7 Quarterly Eligibility/Status Report

X X X Arm., Chin., Russ.


SAR 7A How to Fill Out Your SAR 7 X X X Arm., Chin., Russ.

SAR 7 Addendum

Instructions & Penalties Semi-Annual Eligibility/Status Report”

X X X

1SAWS 2A SAR





SCD 169 Referral To/From Social Security X X

SCD 508 Would you like to register to vote? X X X Farsi, Kor., Lao., Camb., Hmong, Tag., Russ., Jap.,

SCD 1400 General Assistance Program - Request for Medical Information

X X


X X

SCD 2300 Proof Needed X X X

SSP 14 Authorization for Reimbursement of Interim Assistance Granted Pending SSI/SSP Eligibility Determination

X X

1. The SAWS 2A SAR is used when the client completed the SAWS 1 and the CalWIN Statement of Facts (CSF 60). The CF 285 is used for mail-in applications.(See the CF Handbook Chapter 3 for details.)

FORM # FORM NAME

AVAILABLE LANGUAGES




24.8 Cash Assistance Program for Immigrants (CAPI) RRR Packet

The Redetermination (RRR) packet for CAPI includes the informing notices mandated for CAPI and the forms which must be completed to determine CAPI eligibility.

FORM # FORM NAME

AVAILABLE LANGUAGES



X

MC 210 Statement of Facts for Medi-Cal (Used as Statement of Facts for CAPI)

*ONLY if the SOC 804 is not used.



SCD 99 CAPI Redetermination Notice X X



SCD 122 CAPI - General Eligibility Information and Payment Levels


SCD 169 Referral To/From Social Security X X

SCD 573 Cash Assistance Program for Immigrants


SCD 575 CAPI - Important Notice X X X Camb., Chin., Russ., Bos.

SCD 576 CAPI Recipients are Required to Apply for Supplemental Security Income (SSI/SSP)

X X X Camb., Chin., Russ., Bos.

SOC 453 CAPI Statement of Household Expenses and Contributions

X X X Chin., Russ.



24.9 Foster Care RRR Packets

RRR packets are compiled by the Payment Authorization and Control (PAC) unit of the Foster Care Bureau. Social Workers (SWs) and Probation Officers (POs) are responsible to complete and provide the “Statement of Facts Supporting Eligibility for AFDC-FC” (FC2) and “Court Order” documents to the PAC unit.

There are three separate RRR packets for Foster Care. The packets are separated into the following categories:

• Non-Dependent Legal Guardian • Adoption Assistance Program (AAP)• Kin GAP.

24.9.1 Foster Care

The following application forms are generally used for Kin GAP RRR packets:

SOC 804 Statement of Facts Determining Continuing Eligibility for the Cash Assistance Program for Immigrants (CAPI)

X X

SSP 14 Authorization for Reimbursement of Interim Assistance Granted Pending SSI/SSP Eligibility Determination

X X

FORM # FORM NAME

AVAILABLE LANGUAGES


FC 2 Statement of Facts Supporting Eligibility For AFDC-Foster Care (FC)

X X

FC 2 NM State of Facts Support Eligibility for AFDC EFC

X

SOC 158 Foster Child's Data Record And AFDC-FC Certification

X

FORM # FORM NAME

AVAILABLE LANGUAGES




24.9.2 Non-Dependent Legal Guardian

The following application forms are generally used in Non-Dependent Legal Guardian RRR Packets:

FORM # FORM NAME

AVAILABLE LANGUAGES


SAWS 1 Application for Cash Aid, Food Stamps, and/or Medical Assistance

X X X

SAWS 2 Plus Application for CalFresh, Cash Aid and/or Medi-Cal




X X X

SCD 508 Would You Like to Register to Vote? X X X

24.9.3 Adoption Assistance Program (AAP)

The following application forms are generally used for the Adoption Assistance Program RRR packets:

FC 1633A SSI Screening Guide Section A - Disability Screening

X

SOC 161 (NMD)

SOC 161 (9/11) - Six-Month Certification Of Extended Foster Care Participation

X

FORM # FORM NAME

AVAILABLE LANGUAGES


AAP 2 Payment Instructions Adoption Assistance Program

X

AAP 3 Application Recertification X X X

FORM # FORM NAME

AVAILABLE LANGUAGES




24.9.4 Kin-GAP Program

The following application forms are generally used for Kin GAP RRR packets:

FORM # FORM NAME

AVAILABLE LANGUAGES


KG 2 Statement of Facts for Kinship Guardianship Assistance Payment (Kin-GAP) Program

X X

KG1 Kin-GAP Mutual Agreement For 18 Year-Olds

Note: Turning 18.

X X

KG3 Kin-GAP Mutual Agreement For Non-minor Former Dependents

Note: Eligible for extended benefits.

X



X X X


X X

SAWS 2 Plus Application for CalFresh, Cash Aid and/or Medi-Cal

SCD 508 Would You Like to Register to Vote? X X X

SCD 23 Kin-Gap Eligibility Checklist X

SOC 369A Kinship Guardianship Assistance Payment (KIN-GAP) Program Agreement Amendment

X

AD 4320 Adoptions Assistance Program Agreement

X X

SCD 1948 Direct Deposit Enrollment Form (40-79) X X X

SCD 2249 AAP RRR Summary X

FORM # FORM NAME

AVAILABLE LANGUAGES





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Common-Place Handbook Intake/RRR Packets 24. … · signature packet and a packet of informational...

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