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Mc210A: What You Should Know

Download MEDIA COVERAGE FORM. Frequently asked questions and answers to commonly asked questions Do I still have to complete the form? Yes, and please do not sign it without providing the necessary information. What if I do not have the money to file? Please pay the 32 service fee (which will be waived for a single payer/Medicare) and mail, at your expense, copies of both sides  of the form to the addresses for the following: Acknowledgement Department of Health Services 1701 E. Fairway Road Ste. 150 Calais, CA 92 Department of Public Health P.O. Box 123312 Sacramento, CA 94 You may also download a printable version of this form. What if a physician determines that I am eligible for benefits? You may still be eligible but have to pay the amount required by law! (NOTE: this does NOT mean that a physician has the right to determine who will get coverage. It only means that you MUST sign off!) Do I have to file the original form? You need to file either one form if you have received your last medical benefits, or you can file both forms if you have lost your medical benefits and are eligible again. Do that by paying the 32 service fee (which will be waived for a single payer/Medicare). Can I file both forms? Yes, you can file both forms if you lost your medical benefits but are still eligible and can now file a statement of facts for restoration. However, you need to pay for the 32 service fee (2.50 for every page). Can you help me to fill out the form? Yes, I was referred here by a friend who has received both forms. Thank you very much! How long do I have to file the form? If you have lost your medical benefits you need only file one form. But if you lost your medical benefits within 60 days after you applied for benefits, you must file both forms. You must file one form if you have been receiving benefits under any part of the Medical program, or a waiver is available; or are receiving health insurance through HMO's or PPO's.

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