Section 50161 - Statement of Facts Form(a) A Statement of Facts is not required in determining Medi-Cal eligibility for a child receiving aid under the Aid for Adoption of Children program.(b) A public agency, applying on behalf of a child who may be eligible as an MI child who is not living with a parent or relative and for whom a public agency is assuming financial responsibility in whole or in part, shall complete the Application and Statement of Facts for Child in Foster Care Supported by Public Funds, MC 250.(c) An applicant applying for Medi-Cal under any other program shall complete the Statement of Facts, form MC 210.(d) A person applying for Medi-Cal and requesting retroactive coverage shall complete the appropriate Statement of Facts for the current month and the Supplement to Statement of Facts for Retroactive Coverage/Restoration, MC 213, for the retroactive months. If only retroactive coverage is requested, a Statement of Facts, MC 210, shall be completed for one retroactive month for which Medi-Cal is requested and the MC 213 shall be completed for each additional retroactive month.(e) An applicant or beneficiary who has a form CA 2 which has been completed within the last 12 months and which is on file with the county department need not complete the MC 210, unless the county department determines that the applicant's or beneficiary's circumstances have changed to such a degree as to require a new Statement of Facts.(f) Any person requesting a restoration of Medi-Cal-only eligibility shall complete the Supplement to Statement of Facts for Retroactive Coverage/Restoration, form MC 213, unless the county department determines that the applicant's circumstances have changed to such a degree as to require a new MC 210, or unless a new MC 210 is required as part of redetermination of eligibility under Section 50189.Cal. Code Regs. Tit. 22, § 50161
1. Amendment of subsection (c) filed 12-15-77; effective thirtieth day thereafter (Register 77, No. 51).
2. Amendment filed 8-7-78; effective thirtieth day thereafter (Register 78, No. 32).
3. Amendment of subsection (b) filed 8-8-80; effective thirtieth day thereafter (Register 80, No. 32). Note: Authority cited: Sections 10725 and 14124.5, Welfare and Institutions Code. Reference: Section 14005.4, Welfare and Institutions Code.
1. Amendment of subsection (c) filed 12-15-77; effective thirtieth day thereafter (Register 77, No. 51).
2. Amendment filed 8-7-78; effective thirtieth day thereafter (Register 78, No. 32).
3. Amendment of subsection (b) filed 8-8-80; effective thirtieth day thereafter (Register 80, No. 32).