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Forms to Include in the DDSD Referral
“What You Should Know About Your Medi-Cal Disability Application” (MC 017)
This is an optional form which may be given to a client who wishes to apply for MC as a disabled individual. This informational form gives the client an overview of what happens during the application process.
“90-Day Status Letter” (MC 179)
The MC 179 must be sent to the client when a disability decision will not be reached within 90 days. For new applicants, the 90 days begin from the date of application. For continuing recipients, the 90 days begin on the date that the client informs the EW that he/she is disabled.
“Authorization for Release of Information” (MC 220)
The MC 220 authorizes the release of medical records, including testing and treatment records for medical conditions including Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or AIDS-Related Complex (ARC) patients. It also authorizes the release of information other than medical records (i.e., educational records). The form is designed to provide all the items that providers must have in an authorization before they are permitted to disclose protected health information. The MC 220 is printed in English and Spanish.
A signed and dated MC 220 is required for each provider, testing facility, or agency listed on the MC 223/223C, except for the Social Security Administration.
Completion Requirements
EWs must:
- Enter the client's name, valid Social Security Number, and date of birth.
- Ask the client to sign and date the MC 220’s. Once dated, the forms are valid for one year from the date signed.
Important: Do not alter, cross out, white out, or make changes to an MC 220. DDSD will return any MC 220 that has been altered.
Signature Requirements
The MC 220 may be signed by the:
- Client
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Note: Client’s signature must be legible. Hospital medical records will not be available to DDSD by the medical providers if they cannot read the client’s signature.
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- Legal representative of a minor or incompetent client
- Legal representative of a client who is physically incapable of signing
- Legal representative of an incompetent or deceased client
- Legal guardian, conservator, or EW
Note: An authorized representative other than those listed may not sign the MC 220. If someone, other than the client signs the MC 220, he/she must sign their own name with the explanation underneath the signature.
When requesting medical information pertaining to minor consent services, the minor (who is age 12 or older) must sign the MC 220, and the “Minor Consent Services Only” box must be checked.
Exceptions/Special Situations
These rules apply when someone other than the client must sign the MC 220:
Who Must Sign the MC 220
| If the client... | Then the MC 220... |
| Has a guardian or conservator, |
Must include the signature of guardian or conservator and the relationship to client must be checked and/or entered (i.e., legal guardian). Note: Minors age 12 and older must sign a release. In addition, the parent or guardian of every minor must sign a separate release except in those cases involving Minor Consent only. |
| Is incompetent or physically incapable of signing, |
May be signed by the legal or personal representative who is acting on the client's behalf if there is no guardian or conservator.
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| Can only sign with a mark (i.e., “X”), or the signature is not legible, or other non-English character (i.e., Chinese, Arabic), |
Note: The EW may sign as a witness. |
A person representing or assisting a competent applicant/recipient may not be given information about the client unless a signed statement authorizing such actions or an “Appointment of Representative” (MC 306) is included in the DDSD packet.
Reminders
- Applicants should sign their own releases whenever possible. Providers are not obligated to accept a medical release signed by an authorized representative.
- If the individual is a competent adult and is physically capable of signing his/her own medical releases, no other person, including a spouse, may legally release that individual's medical records.
- The MC 220s must be signed by the client unless the client is a minor, has a guardian or conservator, is incompetent or physically incapable of signing the release.
Revocation
The client may revoke and/or modify the authorization at anytime, except for actions already taken. To revoke an authorization, the client must:
Send a written statement to:
Los Angeles State Programs Branch
DDSD- LA State Programs
P.O. Box 992
El Segundo, CA. 90245-0992
Send a copy of the revocation request to any sources that the client no longer wants his/her information disclosed.
“Disability Determination and Transmittal” (MC 221)
The MC 221 is the transmittal and disability determination document shared between the EW and DDSD. It is used for new DDSD referrals or for resubmitted cases.
Note: Use the MC 222 LA to send changes or additional information on pending DDSD cases.
Completion Requirements
| Item | Completion Requirements |
| Items 1-4 and 7 | Provides identifying information about the applicant. Enter all information. |
| Item 2 |
DDSD files all disability records by the client's Social Security Number (SSN); therefore, the valid SSN must be included on the MC 221 whenever it is available. If there is no SSN, then the EW must indicate this by checking the applicable box. Check the “Pending” box if the client has applied for a SSN and the status is pending; check “None” if the applicant is undocumented with no SSN. Do not enter an invalid or pseudo SSN. |
| Item 5 |
The month, day and year that the client applied must be provided as follows:
The “Date Applied” is important because it is the beginning date for the 90-day promptness requirement. |
| Item 6 | List each separate month for which retroactive coverage is requested (not to exceed more than 3 months prior to the “Date Applied”). |
| Item 8 | Check all applicable boxes. (Definitions of all terms listed in Item 8 are included on the back of the MC 221 for easy reference.) |
| Item 9 | Check if the client is currently in the hospital and identify the hospital. If checked, include an MC 220 for the hospital. |
| Item 10 |
Enter any information that you wish to relay to DDSD, such as comments about the client's condition/appearance.
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| Items 11, 12 | Clearly enter worker number, name, phone number and the date the packet is being sent. |
| Items 13-20 | These items will be reserved for DDSD. DDSD will attach a separate document “DDSD Disability Determination - Response to MC 221” (SP2 DDSD 221R) if disability is approved, denied, or if no determination was made. Do not mail the response to the client. |
“DDSD Pending Information Update” (MC 222 LA)
The MC 222 LA is sent to DDSD when the EW becomes aware of new or changed information affecting a pending case.
Types of Changes to Report
The EW must use the MC 222 LA to report the following types of changes to DDSD:
- Change in client’s address,
- Change in client’s name, telephone number or message number,
- Denial or discontinuance of client due to non-medical information (i.e., excess property),
- Withdrawal of application,
- Death of client,
- Receipt of new medical evidence (attach new medical evidence to MC 222 LA), or
- Any other pertinent information which affects DDSD’s actions on a pending case.
“Applicant's Supplemental Statement of Facts for Medi-Cal” (MC 223)
The MC 223 helps DDSD obtain a clear and accurate picture of the client's disabling condition(s). The client is requested to identify all pertinent medical, vocational, social and/or third party sources who can provide relevant information regarding his/her condition. Addresses and telephone numbers of each source must be provided.
Impact of Prior SSA Decision
A prior SSA disability decision determines whether the client must be referred back to SSA, or be allowed to file a Medi-Cal disability application.
It is extremely important that the client informs the EW of any SSA disability decision, including prior, pending and appealed claims. Questions 5 - 5d are intended to help the EW determine whether to deny the DDSD application and refer the client back to SSA or to initiate a DDSD referral.
The MC 223 is designed for completion by the applicant, not the EW; however, the EW should assist as needed.
Completion Requirements: Part I — Personal Information
| Item | Completion Requirements |
| Item 1a | Client’s full name. |
| Item 1b | The client's social security number must be entered. This space must not be left blank. Check “Pending” or “None”, as appropriate. |
| Item 1c | Client's complete date of birth (including year). |
| Item 1d | Enter all known aliases. (This information can be very useful as sometimes medical records are under a different name.) |
| Item 1e | Specify sex. |
| Items 1f-1g | Enter height in feet and inches and weight in pounds. (This can be vital information when evaluating certain disabilities.) |
| Items 2a-2b | The home address (or residence where correspondence can be mailed) must be listed. |
| Item 3 | Enter area code and phone number. Indicate if there is no phone or if there is a message number. (Also indicate if there is a best time to call during normal working hours.) |
| Item 4a-4b | If the client does not speak English, it is important that an interpreter's name and telephone number are listed. |
Part II — Medical Information
| Item | Completion Requirements |
| Item 5a - 5d | Indicate if the client applied for Social Security or SSI disability benefits within the past two years. This information is used to determine if there has been a prior SSA disability decision. And, if so, whether the client must be referred back to SSA or a DDSD referral initiated. |
| Item 6 | The medical conditions that prevent work activity or limit activities of daily living must be listed. Include treated and untreated conditions and attach additional pages if needed. |
| Items 7-8 |
Enter the names, addresses (including ZIP codes), current phone numbers (including area codes), and patient/clinic/member numbers (if applicable) of any hospital or clinic where treatment was received in the last 12 months. DO NOT LEAVE THE ADDRESS BLANK. If the client is unable to provide the address, the EW must make an effort to find the address. If the information cannot be found, this must be stated on the address line or indicated in the county use margin so that DDSD will know that it was not inadvertently omitted. If the client has been seen at additional clinics or hospitals, complete page 8. Reminder: An MC 220 must be completed for each treating source listed on the MC 223. (Check boxes are added to the county use margin to remind EWs that an MC 220 is needed.) |
| Item 9 |
Any doctors seen outside of the hospital(s) or clinic(s) listed in items 7 or 8 in the last 12 months must be listed here. Enter complete names, addresses (including ZIP codes), and current phone numbers (including area codes). If the client is unable to provide the address and the EW has made an effort to find the address but the information could not be located, this must be stated on the address line or indicated in the county use margin so that DDSD will know that it was not inadvertently omitted. If the client has been seen by additional doctors, complete page 8. An MC 220 must be completed for each treating source listed on the MC 223. |
| Item 10 |
All tests performed in the last 12 months must be listed.
Reminder: An MC 220 must be completed for each treating source listed on the MC 223. |
| Item 11 | If client has had additional medical treatment in the past 12 months, enter the information on page 8. |
| Item 12 | Third party sources who know about the client’s medical condition should be listed. They will be contacted if DDSD needs to clarify the client's functional ability. |
| Item 13 | A client may be required to go to additional medical examinations which is scheduled and paid for by DDSD. The client must indicate whether he/she is willing to go to the exams if needed. |
Part III — Social and Educational Information
| Item | Completion Requirements |
| Item 14 | The client is to describe his/her day-to-day activities and how those activities are affected by the client's condition(s). This helps DDSD to determine the extent of the disabling condition and it's effect(s) on the client's ability to function, especially in mental or emotional disorders. ExampleExample |
| Item 15a - 15c |
Indicate the highest grade completed or if a GED was obtained, when it was completed, or if special education classes were involved. If the client states that he/she does not know what level of education was completed or information is not available, the EW should note this in the right margin. DO NOT LEAVE THIS SECTION BLANK. Note: If there are inconsistencies (i.e., the client indicates that he/she completed high school but has significant difficulties reading, writing, or understanding), inform DDSD by making comments in the margin of the MC 223 or in the comments section of the MC 221. |
| Item 16 | Indicate if there was employment within the past 15 years. This includes work which was performed outside of the United States. If work was performed during the past 15 years, the client must complete Part IV. |
Part IV — Work History
| Item | Completion Requirements |
| Item 17a - 17b |
Job titles and the dates worked, including jobs performed outside of the United States, are to be entered. Describe the job, as the actual work performed may differ from what is described in the “Dictionary of Occupational Titles (DOT)” which lists jobs performed in the national economy. DDSD will use the DOT job description if the client does not provide a job description. If more than two jobs were performed in the last 15 years, give the client extra copies of the MC 223, “Part IV - Work History” section to complete. Important: Remember that DDSD is looking for the type of work performed, not the number of various employers that the client has had. For example, if the client is a machinist and he has had three different employers over the past 15 years, then only one work history form must be completed. Guidelines for what to include in the job description:
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Part V — Signature and Certification
Enter signatures and the current date.
“Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age of 18” (MC 223C)
The MC 223C is to be used for applicants filing for MC based on a disability, who have not yet reached their 18th birthday. The client is requested to identify all pertinent medical, vocational, social and/or third party sources who can provide relevant information regarding child’s condition. Addresses and telephone numbers of each source must be provided.
Impact of Prior SSA Decision
A prior SSA disability decision determines whether the client must be referred back to SSA, or be allowed to file a Medi-Cal disability application.
It is extremely important that the client informs the EW of any SSA disability decision, including prior, pending and appealed claims. Questions A-D in Part 3 are intended to help the EW determine whether to deny the DDSD application and refer the client back to SSA or to initiate a DDSD referral.
The MC 223C is designed for completion by the child’s parent, guardian or other personal representative, not the EW; however, the EW should assist as needed.
Completion Requirements: Part 1 — Personal Information
| Item | Completion Requirements |
| Item A | Child's full name. |
| Item B | The child's social security number must be entered. This space must not be left blank. Check “Pending” or “None”, as appropriate. |
| Item C | Child's complete date of birth (including year). |
| Item D | Specify child’s sex. |
| Items E-F | Enter child’s height in feet and inches and weight in pounds. (This can be vital information when evaluating certain disabilities.) |
| Item G | Enter name, relationship, address and the phone number including area code of the person child lives with. The home address must be listed. |
| Item H | Enter mailing address if different than home address. |
| Item I | Enter name and relationship to the child of the person applying for the child. Enter area code and phone number. Indicate if there is no phone or if there is a message number. Also indicate a name of the person to leave message with. |
| Item J | Indicate what language/dialect does the person applying for the child speak and read best. |
Part 2 — The Child’s Illnesses, Injuries, or Medical Conditions
| Item | Completion Requirements |
| Item A | List child’s illnesses, injuries and medical conditions. Include treated and untreated conditions and attach additional pages if needed. Indicate when did it start (month/year). |
Part 3 — Social Security/SSI Information
| Item | Completion Requirements |
| Items A-D | Indicate if the child applied for Social Security disability or SSI disability benefits in the last two years. This information is used to determine if there has been a prior SSA disability decision. And, if so, whether the client must be referred back to SSA or a DDSD referral initiated. |
Part 4 — Special Sources and School Information
| Item | Completion Requirements |
| Item A | Indicate if the child has ever been tested or evaluated by any of the listed agencies, or do any of these agencies have medical record or information about the child. |
| Item B | Enter the names, addresses (including ZIP codes), current phone numbers (including area codes). List all test or evaluations performed (for example, vision, hearing, speech, physical, psychological). Enter the date of the evaluation or test and child’s ID number or claim number. |
| Item C | Indicate if the child is or was attending any type of preschool, day care, and/or after school program. Enter the names, addresses (including ZIP codes), current phone numbers (including area codes), contact person name and dates attended. |
| Item D | Indicate if the child is or was attending school. Enter the names, addresses (including ZIP codes), current phone numbers (including area codes), and names of the teachers. |
| Items E | Indicate if the school makes any special accommodations for the child (for example: adaptive furniture, wheelchair ramps, extra assistance, or attention). Indicate what type of accommodation. |
| Item F | Indicate if the child is in a special education program. Enter the type of special education program. |
| Item G | Indicate if there is a copy of the child’s Individualized Education Plan (IEP), and provide a copy if applicable. |
| Item H | Indicate if the child receives any special counseling or tutoring, and if counseling or tutoring is received at school or outside the school. Enter the names, addresses (including ZIP codes), current phone numbers (including area codes), frequency of visits and dates therapy started and ended. |
| Item I |
Indicate if the child receives any special therapy or any other services for his/her illness or injuries. Include information about any therapy the child receives from parent, guardian, caregiver or in school. Enter the names, addresses (including ZIP codes), current phone numbers (including area codes), name of the person who prescribed the therapy, type of the therapy, frequency of visits and dates therapy started and ended. Note: DO NOT LEAVE THE ADDRESS BLANK. If the client is unable to provide the address, the EW must make an effort to find the address. If the information cannot be found, this must be stated on the address line or indicated in the county use margin so that DDSD will know that it was not inadvertently omitted.
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Part 5 — Medical Information
| Item | Completion Requirements |
| Item A | Enter the names, addresses (including ZIP codes), current phone numbers (including area codes), and hospital/clinic/file numbers (if applicable) of any hospital or clinic where the child received treatment in the last 12 months. |
| Item B |
Any doctors seen outside of the hospital(s) or clinic(s) listed in item A in the last 12 months must be listed here. Enter complete names, addresses (including ZIP codes), and current phone numbers (including area codes). If the child has been seen at additional clinics or hospitals, use Part 9 - Remarks (page 9). Note: DO NOT LEAVE THE ADDRESS BLANK. If the client is unable to provide the address, the EW must make an effort to find the address. If the information cannot be found, this must be stated on the address line or indicated in the county use margin so that DDSD will know that it was not inadvertently omitted.
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Part 6 — Medications
List any prescribed medications, that the child is currently taking. Include name of the prescribed medication, name of the doctor, reason for medication and side effects if any. If the child has additional prescribed medications list them in Part 9 - Remarks (page 9).
Part 7 — Tests
Provide information for medical tests, that the child had or will have and enter the name and address of the test facility, date, and name of the medical professional who sent the child for the test. If there is no space to list all tests, enter additional testing information in Part 9 - Remarks (page 9).
Reminder: An MC 220 must be completed for each test facility listed on the MC 223C Part 5, items A-B. The parent of the child, guardian or other personal representative must sign an MC 220 and appropriate box must be checked.
Part 8 — Work History
If the child ever worked, enter the dates worked, employer name, address (including ZIP code), phone number (including area codes) and the supervisor’s name.
Reminder: An MC 220 must be completed for each employer listed on the MC 223C. The parent of the child, guardian or other personal representative must sign an MC 220 and appropriate box must be checked.
List the child’s job title and describe the work and any problems the child may have doing the job.
Part 9 — Remarks
Enter any additional information relevant to previous questions if applicable.
Part 10 — Signature and Certification
Enter signature and the current date. Must include the signature of the parent, guardian or other personal representative and the relationship to child must be entered (e.g., parent of minor).
“SGA Worksheet” (MC 272)
This worksheet is used to determine if SGA applies when an applicant has gross earnings over the current SGA. The MC 272 may be used to compute the client’s earnings and IRWE/Subsidy deductions as follows:
- Net earnings are at the level of current SGA amount or less: process the application in the usual manner.
- Net earnings are more than the current SGA amount per month: deny claim as client is engaging in SGA.
- Whenever the gross monthly earnings are more than the current SGA amount per month and the EW determines that there is no SGA issue, a copy of the MC 272 must be included in the disability packet. Item 10 of the MC 221 must indicate that there is “NO SGA ISSUE.”
Reminder: If SGA exists, the applicant is NOT eligible for MC as a disabled person.
“Work Activity Report” (MC 273)
This form is given to the applicant to inform him/her of the current SGA limit. It also assists in determining if he/she has any IRWEs or work subsidies that can be deducted from gross earnings.
“Medi-Cal Report on Adult/Child With Allegation of HIV” (DHCS 7035 A / DHCS 7035 C)
These forms are completed by the medical provider when an adult or child alleges having Human Immunodeficiency Virus (HIV), Acquired Immune Deficiency Syndrome (AIDS), or AIDS-Related Complex (ARC). Upon receipt of this form, the EW must review the case for Presumptive Disability (PD).
“DDSD Transmittal” (SCD 1475)
The “DDSD Transmittal” form (SCD 1475) is a coverletter to the DDSD referral packets. It is used by district office DDSD Liaisons when sending referrals to DDSD.
The SCD 1475 is to be completed online, with two hard copies printed. One copy is to be used as a coverletter, and the other copy is to be kept as a log for tracking purposes. The coverletter must be placed on top of the disability referral packets mailed to DDSD in Los Angeles. The disability referral packets must be sent to Los Angeles following the batch process per district office procedures.
Users of SCD 1475
Users of the SCD 1475 are the DDSD Liaisons or the designated professional assistant staff. The designated user must keep a copy of each SCD 1475 sent to Los Angeles as a log for tracking purposes.
Online Form
The SCD 1475 is a Word template (electronic file-form), and it is only available online in the SSA Intranet website.
Instructions for Completion
The SCD 1475 is an online form with various fields. Some fields are permanent, some fields have drop-down menus, and some fields are blank and need to be completed with free form text. Users of the SCD 1475 must follow these instructions to complete the DDSD Transmittal:
| Field | Instructions |
| TO: DDSD Operations Analyst... | This is a permanent field. No changes are allowed. |
| Date Sent To DDSD | This date will automatically be propagated to this field when the user opens the file. No changes are allowed. |
| FROM |
Users will select one option, by clicking the down arrow, from each of the following six drop-down menus:
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| DDSD Referral Packets for Disability Evaluation |
Users will complete this section by entering the following information regarding the disability referral packets:
NOTE: Users can enter up to 12 disability referrals on each SCD 1475. |
| DDSD Information Updates (MC 222 LA) |
Users will complete this section when sending information update to DDSD by entering the following information:
REMINDER: The MC 222 LA must be used when a DDSD packet is pending at DDSD and changes/additional information needs to be submitted to DDSD. |
After all the appropriate fields have been selected/completed, the user must print two copies of the DDSD Transmittal form. One copy must be placed as a cover letter on top of the disability referral packets before they are mailed to Los Angeles, and the other copy must be kept as a log for tracking purposes.
Related Topics
Documents to Include in the DDSD Referral