Chapter 6 - Maternal and Child Health Access
Contents
1. Sexo Ni o Sexo O Ni o O Ni a Fecha de nacimiento mes d a a o Sexo O Ni o O Ni a Lugar de nacimiento nombre del hospital nombre de la cl nica casa etc Direcci n n mero y calle si es disponible i C digo postal Fecha de nacimiento mes d a afio Nombre del reci n nacido O Ni a Nombre del reci n nacido 2 Fecha de nacimiento mes dia afio Opcional Numero de Gateway Nombre del reci n nacido 3 Opcional N mero de Gateway El beb y la madre vivir n en el mismo hogar O S CI No Si su respuesta es no Ha renunciado la madre a sus derechos sobre el reci n nacido S L No Si es as de la fecha de renuncia Este formulario no inicia los beneficios de Medi Cal CalWORKs o Estampillas de Comida Si usted ahora est recibiendo estos beneficios tiene que llamar a su trabajador de elegibilidad para que contin e recibiendo estos beneficios Autorizo la entrega de esta informaci n al Condado del Departamento de Servicios Sociales condado del departamento de bienestar Fecha de petici n Firma del padre madre pariente tutor del nifio po SECTION C Fill in this section if form was completed by person other than parent relative or guardian SECCI N Llene esta secci n si este formulario fue completado por otra persona adem s de un padre familiar o tutor Completed by Please print Completado por P2. If you are not the original assistor it may be necessary to have the client on the phone in person or with a three way phone call or have client sign a Authorized Representative form that can be faxed You can download one at htto www healthyfamilies ca gov English download html Call 800 880 5305 to find out about the status of an application or an existing or previous case Healthy Kids If the applicant thinks she or he might have an open Healthy Kids case call LA Care at 888 452 5437 for assistance Medi Cal The following pages contain resources to help you screen clients for any open Medi Cal case LA County One e App User Manual 114 Help Desk 1 866 429 1979 10 16 07 Checking Medi Cal Eligibility Ask your clients the following questions before filing out the MC 321 Joint Medi Cal Healthy Families application Are you receiving cash CalWORKs benefits If yes as a recipient of CalWORKs the client is entitled to receive Medi Cal Ask the client for his her BIC If the client never received one check eligibility Are you receiving Supplemental Security Income SSI If yes as a recipient of SSI the client is entitled to receive Medi Cal Ask the client for his her BIC If the client never received one and or needs a replacement BIC he she can request one from any Department of Public Social Services DPSS office by presenting his her award letter to the SSI Liaison Do you have a Benefits Identification Card
3. BIC If yes then check eligibility on MEDS AEVS SAEVS or with the client s Eligibility Worker If the client needs a replacement card he she can call his her Eligibility Worker to request one If the client does not know his her Worker he she can call the Los Angeles County Health amp Nutrition Hotline at 1 877 597 4777 Are you enrolled in a health plan or HMO such as Health Net or Care First If yes ask the client if he she has a BIC and check eligibility Ask if the client has a health plan card and if yes explain to them how managed care works To use dental benefits the client needs to show a BIC not a health plan card Have you or your children received medical treatment or dental care anywhere recently If yes how did the client pay for these services or is the client receiving bills Did the client fill out any paperwork at a county or other facility Ask the client to bring any paperwork he she has Help the client to address any bills and obtain retroactive Medi Cal if needed and if eligible Have your children received free immunizations The child may have been put through the CHDP Gateway Did the client receive a BIC Check eligibility The child may need to fill out the joint Medi Cal Healthy Families application to finish the application process LA County One e App User Manual 115 Help Desk 1 866 429 1979 10 16 07 Checking Medi Cal Eligibility T Are there other children in the household already
4. Newborn 2 name first MI last Newborn 3 name first MI last Optional Gateway ID number If yes date child ren given up This form does not start Medi Cal CalWORKs or Food Stamp benefits If you currently get these benefits you must contact your eligibility worker to continue getting these benefits I hereby authorize release of this information to the County Department of Social Services county welfare department Date of request Parent Relative Guardian of the infant signature Do SECTION C Fill in this section if form was completed by person other than parent relative or guardian Completed by PLEASE PRINT Title Telephone number I certify to the best of my knowledge that the information above is verified and accurate Date completed Medi Cal ID number If Medi Cal provider hospital clinic group etc Signature person other than parent relative or guardian For provider billing inquiries concerning or how to bill for infants call the EDS Billing Hotline at 1 800 541 5555 Distribution White County Yellow Hospital Clinic Nurse Midwife CAA AR Pink Parent Relative Guardian MC 330 7 03 State of California Health and Human Services Agency Envie Por Fax Al 21 3 763 8666 Department of Health Services FORMULARIO DE INFORMACION DE RECIEN NACIDOS NO ES UNA SOLICITUD PARA RECIBIR MEDI CAL Por favor use una pluma e imprim
5. s Services CCS services from Regional Centers mental health care etc in addition to Medi Cal emergency services Minor Consent Medi Cal and FamPACT See the Health Consumer Center s brochure at http www healthconsumer org publications htm To make a referral to CCS or for more information on the program call 800 288 4584 Access for Infants and Mothers AIM 1 800 433 2611 http www aim ca gov english AIMHome asp AIM provides health coverage for pregnant women who are less than 30 weeks pregnant at the time their application is accepted The mother s immigration status does not matter This program is for pregnant women who do not qualify for free Medi Cal for pregnancy LA County One e App User Manual 110 Help Desk 1 866 429 1979 10 16 07 Getting Coverage for Medi Cal Babies Medi Cal and Deemed Eligibility for Newborns A Medi Cal application usually requires completing an application form and providing verification such as proof of income But for babies whose mothers had Medi Cal at the time of delivery there s a shortcut for enrollment for the first year of life without any of the usual paperwork Infants born to teens or women who were receiving Medi Cal at the time of the birth and who live with their mothers during the birth month These infants are deemed eligible for full scope Medi Cal for the first year of life Minor Consent Medi Cal moms are treated just like infants of moms with other ki
6. D Dear Dave Cote On 01 20 2007 you began an application for health care coverage at Los Angeles Unified School District Lausd Main Office It appears you have not finished the application process Without a complete and signed application we were unable to submit your application for health care coverage Atthis time your application has expired and we can not continue with your application If your needs or circumstances change we encourage you to reapply for health care coverage When you decide to reapply please bring with you the information as indicated on the attached page Feel free to call me at 1 866 429 1979 with any questions Sincerely Mitchell Smith Medi Cal Authorized Representative Designation Form TO Los Angeles County Department of Public Social Services AA residing at have requested NAME ADDRESS s to represent me in matters concerning my case also authorize your department to release to the above authorized representative any non privileged information requested about my case This authorization is valid until AID TYPE OR TYPES OOOO understand that this authorization will expire on the above date or in DATE one year whichever 15 earlier unless cancel it SIGNATURE OF APPLICANT RECIPIENT o BIRTHOATE SOCIAL SECURITY NUMBER STATE NUMBER IF KNOWN BIRTHPLACE TOWN OR CIT Y COUNT Y STATE SI
7. GNATURE OR NAME OF SPOUSE HE SHE MUST SIGN IF IN THE HOME DATE BIRTHDATE OF SPOUSE BIRTHPLACE OF SPOUSE LDA Perm 7547708 2461 7 21 WE CAN HELP HealthYConsumer Center of Los Angeles Learn About Health Care Programs Find Free or Affordable Health Care Choose the Right Health Care Plan Get Medical Treatment amp Prescriptions Be Heard By Your Clinic or Doctor Use Grievance amp Appeals Procedures CALL 800 896 3203 9 00am 11 45 Mondays Tuesdays Thursdays amp Fridays SERVICES ARE FREE IF YOU ARE A LIMITED INCOME RESIDENT OF LOS ANGELES COUNTY A project of Neighborhood Legal Services nyomon Funded by The California Endowment LA County One e App User Manual 127 Help Desk 1 866 429 1979 10 16 07
8. Resources amp Health Care _ Alternatives one app One Stop Access to Health Car 108 Help Desk 1 866 429 1979 10 16 07 Health Care Program Alternatives What can do for a child teen or family member that does not qualify for Full Scope Medi Cal or Healthy Families s the child under 5 years of age Enrollment is still open in the Healthy Kids program for children who are 5 1 2 and younger You can call 888 452 5437 for more information Does the child s family have an open active case with Kaiser Child Health Plan for another sibling If so you can add a child that is not currently enrolled You can call 800 464 4000 for more information Does the child or family member have an urgent need for health care Refer to LA County Department of Health Services or a Public Private Partnership program depending on need For urgent or ongoing care LAC DHS and PPPs should have free a sliding scale or low cost for some PPP s health care If the family is under 133 1 3 96 of poverty the child or family member may be eligible for free coverage under ORSA Outpatient Reduced Cost and Simplified Application or the PPP s free services if under 133 1 396 of poverty You can call 800 427 8700 to locate a LA County location or a PPP provider 5 the child within the Child Health and Disability Prevention Program CHDP schedule of visits or is a problem suspected or a visit needed outside the schedule for sports physic
9. a firmemente Este Formulario De Informaci n De Reci n Nacidos es para asistirle a la madre elegible para Medi Cal reportar el nacimiento de su beb s a Medi Cal Completando la informaci n en este formulario usted ayuda al condado a confirmar la elegibilidad del reci n nacido Env e por correo o fax este formulario al condado La informaci n del condado se encuentra al reverso de este formulario Cualquier cambio en el hogar tiene que ser reportado al condado por eso env e esta informaci n lo m s pronto posible La madre tambi n puede reportar el nacimiento por tel fono a su trabajador de elegibilidad Si usted est actuando en representaci n de la madre y no es esposo familiar o tutor entonces su firma e informaci n de identificaci n son requeridas en la Secci n Si est entrando por medio del Programa Gateway escriba el n mero del BIC asignado al beb Opcional SECCI NA La tarjeta de Medi Cal de la madre se puede usar durante el mes de nacimiento del beb y el mes siguiente para servicios y cobros del reci n nacido Nombre de la madre nombre inicial de en medio apellido Fecha de nacimiento de la madre BIC o Identificaci n de Medi Cal o N del Seguro Social Direcci n postal n mero y calle o ubicaci n Condado Ciudad C digo postal N mero de tel fono SECCI NB Recordatorio Un beb nacido a una madre con beneficios limitados es elegible para beneficios completos Opcional N mero de Gateway
10. al or foster care exam See http www dhs ca gov pcfh cms chdp If so the child can get up to two months full Medi Cal if s he does not already have Restricted sometimes called Emergency Medi Cal During that time it is possible to receive care for even longer by applying for ongoing coverage To find a CHDP provider you can call toll free 800 993 CHDP CHDP Periodicity schedule of visits Less than 1 month of age 9 months of age 2 years of age 9 12 years of age 2 months of age 12 months of age 3 years of age 13 16 years of age 4 months of age 15 months of age 4 5 years of age 17 20 years of age 6 months of age 18 months of age 6 8 years of age 3 LA County One e App User Manual 109 Help Desk 1 866 429 1979 10 16 07 Health Care Program Alternatives For citizen Qualified Immigrant children has the parent s income been correctly determined deductions countable noncountable income sibling income stepparent issues You want to be sure the child is not actually under 250 of poverty and thus eligible for Healthy Families Is it possible the family member is PRUCOL a Medi Cal category and thus eligible for full scope Medi Cal The most likely reason is that his her immigration status is being adjusted the family has applied for Legal Permanent Residency LPR or green card or in some other way is adjusting the child s status For more information on PRUCOL you can call The Health Consumer Center of Los Angeles
11. alth e App www healtheapp net and have your password reset or you can call the HeA Help Desk at 866 861 3443 Once you have confirmed you new password you must now go to One e App and update it there y Perform other tasks UPDATING YOUR HEALTH E APP O ch P d PASSWORD IN ONE E APP ange rasswor O Change Secret Question To update your Health e App O Set Default Location password in One e App you will View Messages need to Modify Profil ACCEDERE 1 Log in to https thecenter oneeapp org 1 Select Modify profile on the Menu page pioase provide the user account information for the following systems to which One e App may send application Keep clicking Next till you get to information the Remote System User Account Information screen You then can update your Does Liz Ramirez have an active Health e App user account Health e App UserID 00008744 password Remote System User Account Information CAA ID 123456 Health e App User Account Information Health e App Pas Health e App Enrollment Entity Number County Code 80571 Notify su pervisor or anyone else of new password according to agency protocol Health e App User Certified Application Assistor LA County One e App User Manual 121 Help Desk 1 866 429 1979 10 16 07 Password Tip Sheet PASSWORD TIPS Passwords must be changed every 30 days in both One e App and Health e App Seven days before your One
12. at 800 896 3203 Does the child or family member have an urgent need that may be considered an emergency If so s he may be able to use Restricted or Emergency Medi Cal regardless of immigration status Children who have Restricted Medi Cal will not be able to get full scope Medi Cal from the CHDP Gateway but are still eligible for a CHDP exam and immunizations Is the child or teen in need of confidential services for family planning pregnancy rape treatment exam or treatment for a possible Sexually Transmitted Infection outpatient mental health care or alcohol or drug abuse services S he may be eligible for Minor Consent Medi Cal if living in the parents home the parents income will not count immigration status does not matter and parental consent is not required Call the Department of Public Social Service Central Help Line at 877 481 1044 to locate an office to apply Is the teen or family in need of confidential health education reproductive health services such as family planning emergency contraception or a gynecological exam HIV and other STI screening available from the Family PACT program Call 800 942 1054 or see www dhs ca gov pcfh ofp Programs FamPACT default htm to locate a provider Does the child have a serious or chronic medical condition Immigrants ineligible for regular Medi Cal and Healthy Families are still eligible for health care for serious and or chronic medical conditions from California Children
13. date and click on Submit AEVS will give you the clients name eligibility status county code aid code scope of benefits and which health plans if any the client is enrolled in LA County One e App User Manual 119 Help Desk 1 866 429 1979 10 16 07 Frequently Asked Questions What do do if get a Health e App Data transfer error Once the system has completed the data transformation process it will start migrating the application data to the Health e App system When the transfer fails due to System Error you will receive a pop up message that your transmission has failed e Call the One e App Help Desk and notify them of the error received Be prepared to give detailed information including the application ID number and error number the first line in the screen Take a screenshot of the error message and send in an e mail to the One e App Help Desk see Bug Reporting in Chapter 5 LA County One e App User Manual 120 Help Desk 1 866 429 1979 10 16 07 Health e App Password Data Transfer Errors Health e App Data Transfer Password Data Transfer Errors e If the transfer failed after the Health e App password verification some information may have been sent to the Health e App You will need to log in to Health e App look in your workload find the application in question and continue from there e If the reason for the transfer error was your Health e App password being disabled you will need to login in to He
14. e App password expires you will receive a tickler reminder that your password 1 about to expire it will be displayed on the tickler banner on the top of the Menu screen until the user changes the password Health e App does not remind about password changes however it is recommended that you update your Health e App password on the Health e App website or by calling the Health e App help desk to reset every time your One e App password is reset That way you won t receive data transfer errors from the Health e App website from an expired password www healtheapp net or 866 861 3443 You can use the One e App Password for Health e App but not the reverse When you get the reminder follow these steps 1 Change your password in One e App 2 Modify your profile in One e App to change your Health e App Password the same one you changed it to in One e App 3 Go to Health e App and change your password to the new password Password Requirements The following are requirements for the password you create each 30 days It must be at least 8 characters in length It must contain at least one number lt must be a combination of upper and lower case characters e It must contain at least one special character like 96 lt must be case sensitive It matters if you type in capital or lower case letters LA County One e App User Manual 122 Help Desk 1 866 429 1979 10 16 07 Faxing Tip Sheet To complete the application proces
15. ill be issued a five digit number that is good for 24 hours only However depending when you call it may be good for a few hours only until midnight To check eligibility call 1 800 541 5555 Press option 11 16 15 2 Verify PIN number Press 1 for eligibility enter the recipient ID and press Press 2 for Share of Cost SOC clearance 4 Calling DPSS Eligibility Workers Have the client contact his her Medi Cal or CalWORKs worker if a new replacement BIC card is needed The client may also call the Los Angeles County Health amp Nutrition Hotline at 1 877 597 4777 LA County One e App User Manual 116 Help Desk 1 866 429 1979 10 16 07 Checking Medi Cal Eligibility Automated Eligibility Verification Sign Up Form CATE CALIFORMIA HEALTH AND WELFARE AGENCY i JEPARTMENT OF HEALTH SERVICES 714 744 STREET BOK 942722 SACRAMENTO CA 94534 7220 916 657 2941 PETE WHSOM Governor Dear Organization BENEFIT ASSISTANCE TO MEDI CAL BENEFICIARIES When the Department of Health Services DHS transierred from the old paper Medi Cal card to the Beneficiary identification Card or piastic card the fact that many other government agencies and even community based civilian organizations provided assistance and or benefits to welfare recipients in general and Medi Cal recipients in particular were not recognized thereiore many of those organizations are now having problems in veritying eligibility f
16. nds of Medi Cal they are deemed eligible for full scope Medi Cal until the first birthday if they live with the mom in the birth month Reminder Newborns are automatically covered for full scope Medi Cal under the mother s Medi Cal card and number during the birth month and the month after This gives families a little breathing room to inform the County that the baby has been born so that the County can issue a separate Medi Cal card and number for the newborn What is the process for enrolling a deemed eligible infant into Medi Cal using the shortcut The most direct way is to contact the mother s Eligibility Worker preferably by phone If the client does not know who his her Eligibility Worker is they can call 877 481 1044 to find out You also have the option of faxing or mailing a MC 330 Newborn Referral Form attached in Spanish and English to the County You can use the attached copy to fax or download form at http www dhcs ca gov formsandpubs forms Pages MCEBbyNumber aspx FAX TO 213 763 8666 State of California Health and Human Services Agency Department of Health Services NEWBORN REFERRAL di NOT AN APPLICATION FOR MEDI CAL s PLEASE USE INK AND PRESS FIRMLY A The Newborn Referral Form is used to assist a Medi Cal eligible mom to report the birth of her child ren to Medi Cal By completing the information on this form you help the county confirm the eligibility of the newborn Mail or fax
17. or favor escriba en letra de molde Title T tulo Medi Cal number if Medi Cal provider hospital clinic group etc N mero de Medi Cal Telephone number N mero de tel fono s es completado por el proveedor de Medi Cal hospital cl nica grupo etc I certify to the best of my knowledge that the information above is verified and accurate Certifico al mejor de me conocimiento que la informaci n arriba es verificada y exacta Signature person other than parent relative or guardian Firma otra Date completed Fecha en que se complet este formulario persona que no sea un padre familiar o tutor po For provider billing inquiries concerning or how to bill for infants call the EDS Billing Hotline at 1 800 541 5555 Distribution White County Yellow Hospital Clinic Nurse Midwife CAA AR Pink Parent Relative Guardian MC 330 SP 7 03 Eligibility Verification According to our Department of Public Social Services some 60 of the denied Medi Cal applications for children that arrive in Los Angeles monthly either already have Medi Cal or already have started the process to apply Duplicate submissions waste resources that could be used to help more children with enrollment and finding health care Healthy Families Healthy Families will only answer questions from the CAA who originally helped the client until the application is accepted or denied or that person him herself the parent or teen
18. or their clients These organizations used the paper Medi Cal card as a quick means verifying eligibility for various community benefits OHS completed implementation to a one time issue plastic card September 1 1994 Due to confidentiality laws and regulations these organizations are legally barred from access to the Medi Cal Eligibility Data System MEDS any other present means to verily the client s current eligibility Until now the organizations had to rely on the client or call the county welfare office to verity eligibility With the assistance of Electronic Data Systems OHS can now provide these organizations with a modilled version of the Automated Eligibility Verification Systems AEVS which is a voice response system that will enable you lo periorm eligibility verification transactions for Medi Cal and County Medical Services Program recipients using a touch tone telephone A copy ol the Telephone AEVS User Guide is included with this letter as Enclosure No 2 The AEVS service is provided at no cost to the user The AEVS User Guide was developed tor the use of Medi Cal providers seeking billing information Some information will not pertain to your organization AEVS is available by using a touch tone telephone between the hours ol 2 00 A M and midnight seven days a week With reference to page 100 54 2 the enciosed User Guide for Telecnone AEVS the intormation you should have ready to enter using ycur touch lone tele
19. phone when prompted by AZ S is your eight digit PIN the recipient s Medi Cai IO number and the recipient s month and year ol birth and the date the recipient s Medi Cal card was issued This information is required for each eligibility transaction The enrollment procedure to participate in AEVS consists completion of the enclosed AEVS Enrollment Form which is included as Enciosure No 1 You must provide requesied information Once DHS receives the completed enrollment orm you will be issued a non Medi Cal provider number and a PIN number which you must have lo use AEVS ana fellinestdhcs ca gov you have any questions please contact Anha Fellines at 916 552 9507 Sincerely Frank S Martucci Chief Medi Cal Eligibility Branch Enclosures LA County One e App User Manual 117 Help Desk 1 866 429 1979 10 16 07 Automated Eligibility Verification Form Fill out this form and fax to gain access to AEVS Automated Eligibility Verification Systems AEVS Enrcilment Form Ail non rroviders intending to perform eligibility verification through AEVS must complete the Oath cf Confidentiality and provide all other information as requested by this form FF n OATH OF CONFIDENTIALITY As a condition of obtaining access to the Automated Eligibility Verification System maintained Sy the California Department of Heaith Services I we agree to not divulge any information cctained in the co
20. process you can access it from the Menu by selecting the Health e App Fax Cover Note If you use the Menu option to print fax cover sheets you will be asked to conduct an application search From the search results click on Fax in the Retrieve Fax column to retrieve the fax cover sheets Step 2 Fax Verification Documents o For Healthy Kids or CHDP you are required to fax to One e App at 888 398 6328 o Arrange documents behind the permanent and temporary cover sheets o Clearly mark an X on the cover sheet next to those items that are attached o Send the set of two fax cover sheets and documents in each fax transmission o For Medi Cal or Healthy Families you are required to fax to Health e App within 24 hours of submitting the application at 866 848 4976 o Arrange documents behind the fax cover sheet o Clearly mark an X on the cover sheet next to those items that are attached o Sendonly one fax cover sheet and documents in each fax transmission As a best practice we strongly recommend to also fax Health e App documents into One e App for permanent storage This provides easy access to documents if they need to be re faxed to Health e App and stores permanent documents for renewals Step 3 Verify the fax was received For faxes sent to One e App you should verify that the fax was received and is showing up properly To do this 1 Select View Faxes from the Menu 2 Search for the application 3 Inthe search resul
21. receiving aid If yes the client and or other children may be able to be added onto an existing case Check eligibility If the applicant answers Yes to any of the above mentioned questions he she may already be receiving Medi Cal benefits Additionally if the application is for a newborn determine if a Newborn Referral MC 330 should be completed instead of the Joint Medi Cal Healthy Families Application MC 321 HFP Ways of checking eligibility 1 Medi Cal Eligibility Data System MEDS This State system is used by Los Angeles County DPSS Eligibility Workers at provider offices and hospitals at county clinics and hospitals and at the health departments in the cities of Long Beach and Pasadena Automated Eligibility Verification Systems AEVS Non providers can apply to get a PIN number to check eligibility via the telephone To obtain an application for AEVS call 916 552 9492 AEVS will not work however unless the client has Medi Cal In addition AEVS does not have information for pending Medi Cal Supplemental Automated Eligibility Verification System SAEVS Non providers can access a temporary PIN number which is good for 24 hours only Non providers can request a PIN every day if needed e Call 1 800 541 5555 Monday Friday from 8 00 a m to 5 00 p m Press option 11 16 16 Request a temporary PIN number for non provider EDS will ask for first name first letter of last name and agency telephone number You w
22. s you must fax your verification documents e g income rights and declarations proof of residency after submitting an application in One e App This one pager contains tips on the faxing process IMPORTANT Suspend until you are ready to fax Please note that there are some time limits associated with faxing documents We strongly recommend that if you are not ready to fax documents immediately after submitting the application you should suspend the application prior to submitting When the documents are ready for faxing you can continue to submit the application and fax the documents immediately after Step 1 Print the Fax Cover Sheets There are different fax cover sheets for documents for One e App and Health e App as described below o has a one set of two fax cover sheets for documents for each application one for permanent and one for temporary documents These can be used for all four children s programs Medi Cal Healthy Families Healthy Kids and CHDP Fax cover sheets may be printed during the application process by clicking the Generate Fax Cover button at the bottom of the submit page OR by selecting the Menu option Retrieve Fax Cover Sheets o Health e App has one fax cover sheet for each Medi Cal Healthy Families application You will be navigated to the Health e App fax cover sheet during the data transfer process If you forget to print out the Health e App fax cover sheet during the data transfer
23. this form to the county County information is located on the back of this form Any changes to the household must be reported to the county so turn in this information quickly The mother may also report the birth by phone to her eligibility worker If you are acting on behalf of the mother and are not a spouse relative or guardian then your signature and identifying information is required in Section C If entering through Gateway Program enter the BIC number assigned to the infant optional SECTION The mother s Medi Cal card can be used during the birth month and the month following for services and billing for the newborn Mother s name first MI last Mother s date of birth BIC or Medi Cal ID number or SSN Mailing address number and street or location County City uli ZIP code Telephone number SECTION B Reminder A child born to a mother with restricted benefits is eligible for full scope benefits Date of birth month day year Gender Male Female Date of birth month day year O Male Female Date of birth month day year Gender Male Female Where born hospital name clinic name etc Address number and street if available City p ZIP code Will baby and mother live in the same household O Yes O No If no has the mother given up rights to the newborn child O Yes No Newborn name first MI last Optional Gateway ID number Optional Gateway ID number
24. ts click on the Applicant s Name This will take you to the Application Details page To view the faxes click on the column header labeled Fax under Verification Documents LA County One e App User Manual 123 Help Desk 1 866 429 1979 10 16 07 One e App Sample 7 Day Letter one app One Stop Access to Health Insurance Monday January 14 2008 Dave Cote 3600 Oak Hill Ave Los Angeles 90032 Application ID Dear Dave Cote On 01 20 2007 you an application for health care coverage at Los Angeles Unified School District Lausd Main Office It appears you have not finished the application process Without a complete and signed application we can not submit your application for the health care coverage Your application is not complete for the reason s listed in the attached page We cannot finish processing your application please call me so we can arrange atime for you to provide the missing information and complete the interview Y our application will expire on 3 31 2007 You will need to complete a new application if we do not hear from you by the expiration date We know how important itis to obtain health coverage Call me at 1 866 429 1979 to schedule your appointment or with questions Sincerely Mitchell Smith One e App Sample 13 Day Letter one app One Stop Access to Health insurance Monday January 14 2008 Dave Cote 3600 Oak Hill Ave Los Angeles CA 90032 Application I
25. urse of my our assigned duties to unauthorized persons and I we agree to publish or otherwise make public any information regarding persons receiving Medi Cal services such that the persons who received such services are identifiable Access to such data shall Se limited o personnel no require the information in the performance of their duties and to such cthers as may authorized by Department of Heaitn Services I we reccgnize that unauthorized release of confidential information may make me us subject to civil and criminal sanctions pursuant to the provisions of the Welfare and Institutions Code Section 14100 2 Organization Name SIGNATURE 5 DATE Organization Attention to Address City ZIP Code Contact Person Phone __ The purpose cf requesting this access is to When complete fax this form to Ana Fellines 916 552 9478 LA County One e App User Manual 118 Help Desk 1 866 429 1979 10 16 07 AEVS Eligibility Checking by Internet You need to have either a Medi Cal Provider Number or apply for an AEVS non provider number see page 115 Go www medi cal ca gov Eligibility Login asp Click on Transaction Log in on the left hand side Enter your user ID provider number and password and click on Submit Click on Single Subscriber and enter the clients Subscriber ID BIC number birth date the BIC issue date and the service
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