Request for Temporary Medical Exemption Form
This PDF contains instructions for requesting a temporary medical exemption from Medi-Cal Managed Care Plan enrollment. It provides essential information for those whose health conditions may worsen if they enroll in a managed care plan. This form is crucial for individuals needing to maintain their regular Medi-Cal doctor.
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How do I fill this out?
To fill out this form, start by completing Part I, which requires the Medi-Cal member to provide their personal information. Next, submit the form to your Regular Medi-Cal doctor for them to fill out Part II. Ensure every section is filled out to avoid delays in processing your exemption request.
How to fill out the Request for Temporary Medical Exemption Form?
1
Complete Part I of the form with personal details.
2
Have your Regular Medi-Cal doctor complete Part II.
3
Check that all sections are filled before submission.
4
Submit the signed form to the relevant authority.
5
Await confirmation or denial of your medical exemption request.
Who needs the Request for Temporary Medical Exemption Form?
1
Individuals receiving Regular Medi-Cal benefits who wish to maintain their existing medical care.
2
Patients with complex medical conditions not covered by managed care plans.
3
Those whose current doctors do not participate in available Medi-Cal Managed Care Plans.
4
Individuals enrolled in Medi-Cal waiver programs needing additional medical exemptions.
5
People experiencing health issues that may worsen with a change in medical care.
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What are the instructions for submitting this form?
After completing the form, submit it directly to the Department of Health Care Services. You can send it via fax, mail, or online submission depending on your location. Ensure to include all necessary documents to avoid delays in processing your exemption request.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, ensure all requests for medical exemptions are submitted well in advance to avoid any disruption in care. Note that deadlines may vary by county, so be sure to check local guidelines. Keep track of your application's status after submission.
What is the purpose of this form?
The purpose of this form is to allow individuals under the Medi-Cal program to request a temporary medical exemption from enrolling in a managed care plan. This exemption is vital for those whose medical needs cannot be met by available managed care doctors. By preserving access to their regular healthcare providers, beneficiaries can maintain continuity of care during critical health situations.
Tell me about this form and its components and fields line-by-line.
- 1. Name: The name of the Medi-Cal member.
- 2. Benefits Identification Card Number: Unique identifier for the Medi-Cal member.
- 3. Date of Birth: The date of birth of the Medi-Cal member.
- 4. Gender: Select either Male or Female.
- 5. Social Security Number: The member's social security number.
- 6. Medi-Cal Plan Membership: Indicate if the member is part of a Medi-Cal Plan.
- 7. Representative Information: Details if someone is completing the form on behalf of the member.
- 8. Doctor's Name: Name of the Regular Medi-Cal doctor.
- 9. Beneficiary's Signature: Signature of the beneficiary.
- 10. Date Signed: Date on which the form is signed.
What happens if I fail to submit this form?
Failing to submit this form could lead to automatic enrollment in a Medi-Cal Managed Care Plan. This may result in loss of access to your Regular Medi-Cal doctor, impacting your care continuity. Ensure all sections are complete and accurate to prevent unnecessary complications.
- Loss of Access to Doctor: You may be assigned to a different doctor, affecting your treatment.
- Increased Health Risks: Changing doctors can lead to potential health risks.
- Delayed Care: Enrollment in managed care may delay necessary treatments.
How do I know when to use this form?
- 1. Complex Medical Conditions: For patients with multiple health issues needing specialized care.
- 2. Non-Participating Doctors: When your regular doctor does not accept managed care.
- 3. Continuity of Care: To continue care without disruptions during critical treatment periods.
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