Form Mc 274 Tb - Medi-Cal Tuberculosis Program Application
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1
2
3Department of Health Care Services
State of California—Health and Human Services Agency
MEDI-CAL TUBERCULOSIS PROGRAM
APPLICATION
If you are applying only for the Medi-Cal Tuberculosis Program, please complete this form.
NOTE: You must be a U.S. citizen or have satisfactory immigration status to receive benefits under this
program.
1. PATIENT/APPLICANT NAME
COUNTY USE ONLY
Case name:
2. MAILING ADDRESS—Number/Street
City
ZIP Code
3. IF NO PERMANENT ADDRESS, TELL US WHERE YOU CAN BE REACHED
Case number:
4. TELEPHONE NUMBER(S)—Home
Work
Message
(
)
(
)
(
)
5. DATE OF BIRTH
6.
SOCIAL
SECURITY NUMBER
/
/
____________
___________
____________
—
—
Month
Day
Year
County of application:
7. THE LAW SAYS WE MUST GET YOUR ETHNIC GROUP AND PRIMARY LANGUAGE.
IF
YOU DO NOT WANT TO COMPLETE
THESE ITEMS, THE COUNTY WILL DO IT FOR YOU. THIS WILL NOT AFFECT YOUR ELIGIBILITY.
County of residence:
a.
Ethnic Group:
White
Black
Hispanic
Filipino
Chinese
Hawaiian
Asian Indian
Laotian
Cambodian
Japanese
CWD records cleared
American Indian
Korean
Guamanian
Samoan
Vietnamese
or Alaskan Native
Other Pacific Islander (specify): ______________________________________
Ethnic group:
b. Language:
English
Cantonese
Lao
Tagalog
Spanish
Primary language:
Cambodian
Vietnamese
American Sign
Other (specify): _____________
If applicant is under 18 years of age, parent/spouse information:
NAME
ADDRESS—Number/Street
City
ZIP Code
CERTIFICATION AND PERJURY STATEMENT
I certify that I understand and agree that I have to comply with eligibility rules. I understand that the statements I
have made on this form may be checked and verified.
I declare under penalty of perjury under the laws of the United States of America and the State of California that the
information I have given on this form is true, correct, and complete.
SIGNATURE (OR MARK) OF APPLICANT OR AUTHORIZED REPRESENTATIVE
DATE SIGNED
➤
SIGNATURE OF INTERPRETER OR WITNESS TO APPLICANT’S MARK
➤
ORIGINAL—County Welfare Department
COPY—Provider
COPY—Patient
MC 274 TB (05/07) Part A—Application
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