TB Application Process

Most TB applicants are referred by the TB and VMC Ambulatory Care clinics. Some TB patients will be referred by private physicians and community health clinics. Applicants may also initiate an application on their own at any one of the district offices. DO NOT REFER TO MBA.

TB Application Packet

The client must complete the following forms when applying for the TB program:

Identification and Intake Record (SCD 41).
Medi-Cal Tuberculosis Program Application (MC 274TB).
Application for Health Insurance (CCFRM 604)
The Important Information for Persons Requesting Medi-Cal (MC 219) must be provided but completion is not required.
Supplement to Statement of Facts for Retroactive Medi-Cal (MC 210A), if retroactive coverage is requested.
Health Insurance Questionnaire (DHS 6155), if applicable.

TB Application (MC 274TB)

The TB application form is the “Medi-Cal Tuberculosis Program Application” (MC 274TB). It is a three part form consisting of:

Part A — Application. This is the actual TB application form. It must be completed for each TB applicant. A SAWS 2 Plus cannot be used in lieu of the MC 274TB, Part A.

Note: The MC274TB, Part A is used ONLY for the TB program. It cannot be used for other MC or public assistance programs.

Part B — Referral. This form is the physician's certification that the client is TB-infected. One form must be completed for each TB applicant. No other forms or statements are acceptable. The MC 274TB, Part B certification must be completed by a physician.
Part C — Authorization for Clinic Assistance. This form is signed by the applicant and a TB clinic staff member when the client wishes the TB clinic to assist in the application process.
The completion of this form enables the clinic to assist their patients with the TB application.

Homeless Applicant

TB-infected applicants who are homeless and are patients of the TB clinic at 976 Lenzen Ave., San Jose, CA 95126, may use the clinic address as their mailing address, or designate another mailing address.

When unable to contact a homeless client, EWs must complete the eligibility determination through contact with the TB clinic whenever possible. Some homeless clients may continue to receive treatment at the clinic and may be reached at the next clinic appointment.

Individuals in LTC

Individuals in Long Term Care (LTC) who are TB-infected do not receive benefits from the TB Program, as coverage is limited to TB-related outpatient services.

individuals in LTC who are eligible for regular full-scope benefits will have their TB care covered under the regular MC program.

Plastic BIC

Individuals eligible for the TB Program receive an MC Benefits Identification Card (BIC).

MC providers are alerted through the eligibility verification system that the TB program (Aid Code 7H) covers only outpatient TB-related services. The message to the provider says “OUTPATIENT TB-RELATED SERVICES ONLY AT NO SHARE OF COST”.

Retroactive Benefits

There is three-month retroactive eligibility for the TB program. The applicant completes the “Supplement to Statement of Facts for Retroactive Medi-Cal” (MC 210A) for retroactive TB coverage.