Mc171 2026

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The document outlines the procedures for admitting and discharging patients in long-term care facilities under the Medi-Cal program in California. It includes sections for patient information, admission details, discharge reasons, and instructions for completing and distributing the notification form. The document emphasizes the importance of documenting Medi-Cal coverage and provides guidelines on how to handle costs associated with care.

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Click ‘Get Form’ to open the mc171 in the editor.
Begin by filling out the patient’s name, facility name, and social security number in Section I. Ensure accuracy as this information is crucial for processing.
For admissions, complete Section II by entering the Medi-Cal ID number and admission date. Indicate if the patient has Medicare Part A and provide details about their expected length of stay.
In Section II, check the applicable boxes regarding current income sources and provide the address prior to admission. This helps determine eligibility for coverage.
For discharges, navigate to Section III. Fill in the discharge date and reason, ensuring you include a forwarding address if applicable.
Finally, review all entries for completeness before saving your work. Use our platform's features to sign and distribute the form as needed.

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