MCS Assessment 2 | MCS, Inc

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Phone: 877.633.4435

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Free Medi-Cal Assessment (Single)

Go to the assessments only if you Do Not Have Medi-Cal

Free Medi-Cal Assessment (Married)

Medi-Cal Assessment 2(test)

First Name

Last Name

Email

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Country

Phone

Additional Info

Relationship to Appplicant

Would you like Text Notifications

How Did You Hear About Us?

Medi-Cal Applicant

Current Marital Status

Married

Divorced

Widow (er)

Never Married

Are You Currently on Medi-Cal?

YES

NO

Medi-Cal Application in Process

Veteran

YES

NO

Surviving Spouse of a Veteran

What do you want to accomplish with Medi-Cal?

Age

Mental Capacity

Good

Fluctuating

No Capacity

Does anyone have Power of Attorney?

If Yes, Who is the Power of Attorney?

Curent Residence (meaning where is resident housed?)

Home

Skilled Nursing Facility

Assisted Living

Board & Care

Hospital

Living with a Family Member

If SNF, AL, or Board and Care: Name of Facility or Hospital

Date Admitted

Address of Facility or Hospital

City, Zip Code

Monthly Rent at Facility

Applicant's Adult Children (how many)

Applicant's Minor Children (how many)

Health Insurance

Health Insurance Monthly Premium Amount

Dental Insurance

Dental Insurance Monthly Premium Amount

Vision Insurance

Vision Insurance Monthly Premium Amount

Life Insurance

YES

NO

Life Insurance Cash Surrender Value Amount

Vehicle(s) (year, make, model)

Do you own a Home?

YES

NO

In the Last 30 Months was Anything:

Transferred

Sold

Gifted

NO

Do you have a Living Trust?

Do you have any Burial Arranged?

Applicant's Assets / Checking Account $

Applicant's Assets / Savings Account $

Applicant's Assets / Retirement Account $

Applicant's Assets / Annuities Account $

Applicant's Assets / IRA Account $

Applicant's Assets / Stocks/Bonds $

Applicant's Assets / Other $

Income (Please list 'source' and 'amount' for each type)

SPOUSE (section) / SPOUSE NAME:

Spouse / Age

Spouse / Mental Capacity

Good

Fluctuating

No Capacity

Current Residence

Home

Skilled Nursing Facility

Assisted Living

Living with Family Member

Hospital

Spouse's Adult Children (how many)

Spouse's Minor Children (how many)

Spouse / Health Insurance

Spouse / Health Insurance Monthly Premium Amount

Spouse / Dental Insurance

Spouse / Dental Insurance Monthly Premium Amount

Spouse / Vision Health Insurance

Spouse / Vision Health Insurance Monthly Premium Amount

Spouse / Life Insurance Cash Surrender Value Amount

Spouse / Vehicle(s) (Year, Make, & Model)

Spouse / Do you Own a Home

YES

NO

Spouse / In last 30 Months was Anything

Transferred

Sold

Gifted

NO

Spouse Assets / Checking Account $

Spouse Assets / Savings Account $

Spouse Assets / Retirement Account $

Spouse Assets / Annuities Account $

Spouse Assets / Stocks/Bonds Account $

Spouse Assets / Other $

Spouse Income (List Source & Amount for each type of income)

I accept terms & conditions

Go to Book Appointment After Submission of Medi-Cal Assessment

CONTACT

NAME:

PHONE

Email

Subject

Message and or Medi-Cal Qustions

Medi-Cal Consulting Services

417 South Sherman Ave.

Corona, CA 92882

Mail: info@medihelper.com

Tel: 877.633.4435

or: 951.789.0065

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