XXX

026 Compton COUNTY OF LOS ANGELES

211 E ALONDRA BLVD
COMPTON, CA 90220-3813
Date: 10/10/2024
Case Name: SHAWNTAE L ADAMS
Case Number: B204M74
Worker Name: Customer Service
Worker ID: 19DP26MN0E
Worker Phone Number: (866) 613-3777

DPSS - CSU III - NORTHRIDGE

9451 CORBIN AVE STE 200
NORTHRIDGE, CA 91324-9935 SHAWNTAE ADAMS
20255 WINTON ST
CORONA, CA 92881-4826

MEDI-CAL REDETERMINATION FOR December 2024

THIS REDETERMINATION FORM IS DUE BACK TO US BY 12/10/2024

Please complete and return the enclosed Medi-Cal Redetermination Form(s). The information requested is
needed to establish your continued eligibility to Medi-Cal benefits and your benefit level. Please return the
form(s) to us in the enclose envelope. Place this coversheet on top of the form so that the DPSS office address
shows through the window in the enclosed envelope.

THE DOCUMENT(S) MUST BE RECEIVED BY THE COUNTY BY THE DUE DATE SHOWN
ABOVE OR YOUR MEDI-CAL BENEFITS MAY BE TERMINATED

REMEMBER

Even if you are employed you may be eligible to receive Medi-Cal benefits.
Receipt of Medi-Cal does not count against any CalWORKs time limits.
You do not have to receive CalWORKs to receive Medi-Cal benefits.

If you have any questions or need more information about this form, call your eligibility worker whose name and
telephone number are listed at the top of this form.

MEDI-CAL RENEWAL COVERSHEET (11/14)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF HEALTH CARE SERVICES

You may lose

your Medi-Cal if
Medi-Cal Renewal Form you do not
You can get this form in another language or accessible format of your choice. respond by
To ask for help in your language, call: SCAN ME
To complete 12/10/2024
1- (866) 613-3777 (TTY: 1- (877) 597-4777 ). your renewal
online.

20255 WINTON ST Notice date: 10/10/2024

CORONA, CA 92881-4826 Case number: B204M74
Case name: SHAWNTAE L ADAM
Worker name: Customer Service
Worker telephone number: (866) 613-3777

It’s time to renew benefits for:

Name Date of birth

SHAWNTAE ADAMS 08/03/1985

Household members not on this form will get a separate letter about their Medi-Cal.

Step 1. Read the form and answer the questions

Step 2. Sign and date on the Declaration and Signature page
Step 3. Send the form with proof by the due date of 12/10/2024

Easy ways to give us your form and proof:

Online By mail By phone In person
at www.benefitscal.org in the envelope that at 1- (866) 613-3777 to 026 Compton
or coveredca.com. came with this (TTY: 1- (877) 597-4777 ).
letter.
at 211 E ALONDRA BLVD
COMPTON, CA 90220-3813

They are open

Monday through Friday,
?
Questions? Call your local county office at
[1- (866) 613-3777 ] before the due date. 08:00 AM to 05:00 PM

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Your contact information
Review your information Update or add new information below
This information is correct. If correct, go I have updated my information below. Only write
to the next section. in new or changed information.
Name Name (first, middle, last)
SHAWNTAE ADAMS
Home address Home address Apartment #
17600 S SANTA FE AVE STE B
BLDG 42 City State ZIP code
COMPTON, CA 90221-5429
Mailing address (If different from home address or you
Mailing address do not have a home address)
20255 WINTON ST
CORONA, CA 92881-4826
City State ZIP code

Phone Phone
Home: (725) 296-2041
Home - - Cell - -
Cell:
Work - - Other - -
Other:
Email Email (optional):
[email protected]
Language to write to you in Language we should write to you in:
English
Language to speak to you in Language we should speak to you in:
English

Best way to contact you: Email Phone Mail

Do you need an authorized representative?

Call your local county office at 1- (866) 613-3777
(TTY: 1- (877) 597-4777 ) if you need to:
■ Appoint an authorized representative such as a family member, friend, caretaker,
attorney, or advocate to accompany, assist, or represent you with your Medi-Cal
eligibility and enrollment
■ Change your authorized representative

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 If you need to add more people or information in any of the
sections, please write it on a separate sheet of paper (or you can
make a copy of the page) and send it with your renewal form.

Household members
We need information about you and every member of your household.
This includes:
■ Your spouse or registered domestic partner
■ Your children who live with you
■ All parents who live in the home with their children
■ Anyone on your federal income tax return, if you file one. You don’t need to file taxes to apply for
health insurance.
■ If you are claimed as a dependent on someone else’s tax return, you must include all members
of the tax filing household that claimed you, and any family members living with you.
■ Anyone else who lives with you will need to file their own application if they want health
insurance.(For example: a boyfriend, girlfriend or roommate)

Review your household member information.

Name Relation to Address Is this correct? If
yes, go to the next
SHAWNTAE ADAMS section. If no
update below.

Yes No

Yes No

Yes No

continued on the next page »

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» continued

Update or add new household member information.

Tell us about changes to your household in the last 12 months.
For example, a household member got married, had a baby, moved into or out of your home,
was incarcerated, or if there was a death in the household.

Name Relation to What changed?

(first, middle, last) [case holder’s name]

1.

2.

3.

Tax information
The primary taxpayer is the person listed first on the tax return and on this table.
Review your tax information.
Name Does this Does this What is this Is this correct? If
person plan to person person’s tax yes, go to the
file a federal tax expect to be filing status? next section. If no,
return? required to update below.
file taxes?
Primary Tax Filer

SHAWNTAE ADAMS No No Primary Tax Filer Yes No

Yes No

continued on the next page»

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» continued

Update or add new tax information.

Has your primary tax filer changed? (This is the person listed first on the tax return.)

Yes No If yes, primary tax filer’s name:

Name Does this person Does this person What is this person’s tax
(first, middle, last) plan to file a expect to be required filing status?
federal tax return? to file a tax return?

Married filing jointly with:

Married filing separately

Single
1. Yes No Yes No Head of household
Dependent Claimed by:

Non-tax filer

Married filing jointly with:

Married filing separately

2. Single
Yes No Yes No
Head of household
Dependent Claimed by:

Non-tax filer

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Income
Income is money you get from a job, self-employment, or other sources such as Social Security or pension.
You must attach current proof of all incomes. For example:
■ Recent pay stubs
■ Benefits or award letters
■ Last year’s tax return

Review your income information.

Name Source of Income How often? Is this correct?
income before taxes (annually, If yes, go to the next
or deductions monthly, every 2 section. If no, give the
(Federal weeks, twice a date of the last time you
taxable month, weekly, got this income. Then
income) daily, or hourly) update or add below.

Yes No
/ /

Yes No
/ /

Yes No
/ /

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» continued

Update or add new income information.

Examples of most common income types:
■ Income from your job ■ Spousal support received:
■ Income from self-employment Fill in the most recent date or modification date of
■ Social
your divorce or separation agreement
Security retirement,
(month/day/year) here:
survivors, and disability benefits
/ /
■ Unemployment benefits

Name What is the Your income Start date How often? Is this income
(first, middle, last) source of before taxes (month, day, (annually, expected to
this or year) monthly, every 2 continue?
income? deductions weeks, twice a If no, give
(Federal month, weekly, the last date you
taxable daily,or hourly) expect to get
income) this income.

Yes No
1. $
/ /

Yes No
2. $
/ /

Yes No
3. $ / /

Does anyone’s income change from month to month?

Yes No If yes, tell us what the total income will be for the next 12 months.
This is to help get the correct annual income amount.

Name What is your total income expected

(first, middle, last) to be for the next 12 months?

1. $

2. $

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Expenses and deductions
Reporting tax expenses and deductions that you pay, may lower the income Medi-Cal uses to determine
your eligibility. You must attach current proof of expenses and deductions. For example:
■ Profit and loss statement
■ Tax return

Review your expenses and deduction information.

Name Type of expense or Amount How often? Is this correct?
deduction (monthly, If yes, go to the next
quarterly, section.
annually) If no, update below.

$ Yes No

$ Yes No

Update or add new expenses and deductions information.

Examples of most common expenses and deductions:
■ Self-employment expenses ■ Alimony paid: Fill in the most recent date or
■ Student loan interest modification date of your divorce or separation
■ IRA contributions agreement (month/day/year) here:
/ /
Name (first, middle, last) Type of expense or Amount How often?
deduction (monthly, quarterly,
annually)

1. $

2. $

3. $

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Other health insurance
Tell us about any health coverage that you have that is not from Medi-Cal or Medicare. For example, you
may also have health insurance from Covered California or a family member’s job.
If you do not have other health insurance, skip this section and go to the next.

Review your health insurance information.

Name Insurance Type of Premium How often Is this
company Insurance amount (monthly, correct? If
(such as health, you pay quarterly, yes, go to the
dental, vision, annually) next section. If
pharmacy) no, update
below.

$ Yes

$ Yes

Update or add new health insurance information.

Name Insurance Type of Premium How often
(first, middle, last) company Insurance amount (monthly, quarterly,
(such as health, you pay annually)
dental, vision,
pharmacy)

1. $

2. $

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Household changes

Medi-Cal
Does anyone in your household who is not on Medi-Cal want to apply? If yes, fill in below.
Name (first, middle, last) Date of birth Social Security number, if they have
one, of the person who wants Medi-Cal
- -

Pregnant
Is anyone in your household pregnant? If yes, fill in below.
Name (first, middle, last) Due date How many babies
are expected?

/ /

Former foster youth

If anyone in your household is between 18 and 26 years old, were they in foster care in any state on
or after their 18th birthday? If yes, fill in below.

Name (first, middle, last) State (example: California)

Immigration or citizenship
Has anyone in your household who now has Medi-Cal had a change in their immigration or
citizenship status in the past 12 months? If yes, fill in below.

Name (first, middle, last) New status number

Disability
Does anyone in your household have a physical, mental, emotional, or developmental disability? yes

Name (first, middle, last) Is the disability a result of an

injury?
Yes No

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» continued

Student
Is anyone in your household 19 or 20 years old and a full-time student? If yes, fill in below.

Name (first, middle, last)

Medicare
Does anyone in your household have Medicare? If yes, fill in below.
Name (first, middle, last) Medicare number Monthly premium you
pay
$

Long-term care
Is anyone in your household in long-term care? If yes, fill in below.
Name of person in long-term care Entrance date Discharge date
(first, middle, last) (month/day/year) (month/day/year)
/ / / /

Long-term care facility name Long-term care facility address

Spouse or registered domestic partner’s name Spouse or registered domestic

(first, middle, last) partner’s address if different

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Health program information and referrals
This section is optional. You can choose not to answer, but your answers help us refer you to available
services.

1. Do you want information on the no-cost health program for children under 21 (Child Health and
Disability Prevention Program, also known as CHDP)?

Yes No

2. Do you want information on the no-cost supplemental food program for people who are pregnant
or breastfeeding and children under 5 (Women, Infants, and Children Program, called WIC)?

Yes No

3. Is any household member living in the home receiving kidney dialysis-related services?

Yes No If yes, who:

4. Has any household member living in the home received an organ transplant within the last 2
years?

Yes No If yes, who:

5. Do you want information on the Personal Care Services Program, an in-home care program for
aged, blind, or disabled persons (also called In-Home Supportive Services)?

Yes No

6. Does anyone in your household need help with long-term care or home and community-based
services?

Yes No If yes, who:

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Declaration and signature
■ I declare under penalty of perjury under the laws of the state of California that what I say below is true
and correct.
■ I understood all questions on this renewal form and gave true and correct answers as far as I know.
Where I did not know the answer myself, I made every reasonable attempt to confirm the answer with
someone who did know. I have read or had read to me the privacy statement, rights, and responsibilities
on the following pages.
■ I know that if I do not tell the truth on this renewal form, there may be a civil or criminal penalty for perjury
that may include up to four years in jail (See California Penal Code section 126). I know that the
information in this renewal form will be used to decide if the people who are applying qualify for health
insurance. The Medi-Cal program and Covered California will keep the information private, as required by
federal and California law.
■ If anything changes on this renewal form for any person applying for health insurance, I agree to notify
the Medi-Cal program or contact my local county office within 10 days of any change. If I have insurance
through Covered California, I agree to report any changes within 30 days.

Sign and date below.

Signature of applicant/beneficiary or authorized representative Date (month/day/year)

10/26/2024

Remember to attach all current proof if

required, and all additional copies or
extra pages.

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Keep for your records
These pages contain important information about privacy statement, rights and responsibilities, right to
appeal, and nondiscrimination policy, and filing a discrimination grievance.

Privacy statement
This renewal form is for renewing Medi-Cal benefits through the Department of Health Care Services
(DHCS) and determining eligibility for health insurance through Covered California. The personal and
medical information you provide on it is private and confidential. DHCS or Covered California needs it to
identify you and the other people on this renewal form and to administer our programs.

We will share your information with other state, federal, and local agencies, contractors, health plans, and
programs only to enroll you in a plan or program or to administer programs, and with other state and federal
agencies as required by law.

You must answer all of the questions on this renewal form unless marked “optional” or if you are directed
otherwise. If your renewal form is missing anything that we require, we will contact you to get it. If you do not
provide it, we will not be able to make a decision on your renewal. You may have to submit a new
application. Or you may not be able to get health insurance through Covered California or your application
for benefits renewal may be denied.
In most cases, you have the right to see personal information about you that is in federal and state records.
You can see it in an alternative format such as large print if you need that. For more information or to see
Covered California records, contact the Privacy Officer at:

The Department of Health Care Services Covered California

Attn: Information Protection Unit Attn: Privacy Officer
P.O. Box 997413, MS 4721 P.O. Box 989725
Sacramento, CA 95899-7413 West Sacramento, CA 95798-9725
Phone: 1-866-866-0602 Phone: 1-800-300-1506
TTY: 1-877-735-2929 TTY: 1-888-889-4500

DHCS shall comply with the requirements of 45 C.F.R. Parts 160 and 164, California Civil Code §§
1798 – 1798.78, CA Welfare and Institutions Code (WIC) Section 14005.37, CA WIC Section 14011
and Article 3, Chapters 5 and 7, Parts 2 and 3, Division 9, and other applicable laws in the storage,
use, and release of the information provided in this form.

Covered CA: 42 U.S.C. § 18031; CA Government Code §§ 100502(k) and 100503(a).

You can find the Notices of Privacy Practices for the Medi-Cal program at www.dhcs.ca.gov and for
Covered California at www.CoveredCA.com.

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Rights and responsibilities
■ The information I gave on this renewal form is true as far as I know. I know that I may be subject to a
penalty if I do not tell the truth.

■ I understand that the information I give will be used only to see if those in my family who are applying to
renew health insurance will qualify.
■ I understand that the Medi-Cal program and Covered California will keep my information private, as the
law requires. For more information, or access to personal information in records maintained by the Medi-
Cal program and Covered California, I can contact my local county office. Or I can contact the Covered
California Privacy Officer at 1-800-300-1506 (TTY: 1-888-889-4500).
■ I understand that to be eligible for Medi-Cal, I am required to apply for other income or benefits to which
I or any member of my household is entitled, unless he or she has good cause for not doing so.
Examples of such income or benefits are pensions, government benefits, retirement income, veteran’s
benefits, annuities, disability benefits, Social Security benefits (also called OASDI or Old Age, Survivors,
and Disability Insurance), and unemployment benefits. But such income or benefits do not include public
assistance benefits, such as CalWORKs or CalFresh. If I have a question about a possible source of
income, I can call my local county office or Covered California at 1-800-300-1506 (TTY: 1-888-889-4500)
for help.
■ If I am found eligible for Medi-Cal, I must tell my county eligibility worker about any changes that may
affect my eligibility for health insurance within 10 days of the change to my local county office.
These changes include, but are not limited to:
» I move
» my income changes
» my household changes (for example, marriage/divorce, become pregnant, or have a child(ren))
» I become qualified for other health insurance
■ If I am enrolled in Covered California, I understand I must report changes within 30 days. I can call
Covered California at 1-800-300-1506 (TTY: 1-888-889-4500) or visit CoveredCA.com.
■ I understand that I must report income changes to my local county office because it may affect the
eligibility for Medi-Cal benefits or Covered California for the amount of state and federal financial help
that I may be eligible to receive. I also understand if I receive too much financial help during the benefit
year, I will have to repay the extra premium assistance or state subsidy back to the IRS or California
Franchise Tax Board when I file my federal and state income taxes for the benefit year.

■ I give my permission to Covered California and the Medi-Cal program to check other agencies computer
records to verify citizenship or whether I am lawfully present in the U.S., tax information,’and other
information related only to eligibility to see if I and other people on this renewal qualify for health
insurance.

■ I understand that as required by law, the information I provide about myself and other people on this
renewal for Medi-Cal will be checked by computer with facts given by employers, banks, SSA, Internal
Revenue Service, Franchise Tax Board, social services and other agencies to see if I or other people on
this renewal qualify for health insurance.

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 ■ I know that if Medi-Cal pays for a medical expense, any money I or anyone on this renewal form gets
from other health insurance or legal settlements related to that expense will go to Medi-Cal as payment
for the expense until the expense is paid in full.
■ For parents whose child or children qualify for Medi-Cal: I know I will be asked to help the agency that
collects medical support from any parent on this renewal form who does not live with the child and does
not send support for the child. If I think that helping will harm me or my children, I can tell the Medi-Cal
program and I will not have to help.

Right to Appeal
If I think the Medi-Cal program or Covered California has made a mistake, I can appeal its decision.
To appeal means to tell someone at the Medi-Cal program or Covered California that I think its decision is
wrong and ask for a fair review of the action.

I know that I must file an appeal within 90 days of the decision. I know that I can represent myself or have
someone else represent me in my appeal, such as an authorized representative, a friend, a relative, or a
lawyer.
I know that if I need help, someone at the Medi-Cal program, Covered California, or the local county office
can explain my case to me.
California Department of Social Services
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, California 94244-2430
Fax: 1-833-281-0905
Toll free: 1-855-795-0634 or
Public Inquiry and Response toll free: 1-800-952-5253 or TDD 1-800-952-8349

Nondiscrimination Policy
The Medi-Cal program (DHCS) and Covered California comply with applicable federal and state civil rights
laws and do not unlawfully discriminate on the basis of race, color, religion, ancestry, national origin, ethnic
group identification, age, mental disability, physical disability, medical condition, genetic information, marital
status, sex, gender, gender identity, or sexual orientation.
The Medi-Cal program (DHCS) and Covered California do not unlawfully exclude people or treat them
differently because of race, color, religion, ancestry, national origin, ethnic group identification, age, mental
disability, physical disability, medical condition, genetic information, marital status, sex, gender, gender
identity, or sexual orientation.
The Medi-Cal program (DHCS) and Covered California provide free aids and services to people with
disabilities to communicate effectively with us, such as qualified sign language interpreters and written
information in other formats (large print, audio, accessible electronic formats, and other formats).

The Medi-Cal program (DHCS) and Covered California also provide free language services to
people whose primary language is not English, such as qualified interpreters and information written

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in other languages. If you need these services, contact the DHCS Office of Civil Rights at 1-916-440-7370,
(Ext. 711, California State Relay) or email [email protected], or contact Covered California at
1-800-300-1506 (TTY: 1-888-889-4500).

Filing a Discrimination Grievance

If you believe that the Medi-Cal program (DHCS) or Covered California has failed to provide these services
or you have been discriminated against in another way on the basis of race, color, religion, ancestry,
national origin, ethnic group identification, age, mental disability, physical disability, medical condition,
genetic information, marital status, sex, gender, gender identity, or sexual orientation, you can file a
grievance with the Medi-Cal program’s (DHCS’s) Office of Civil Rights or the Covered California Civil Rights
Coordinator:

Medi-Cal Program (DHCS) Covered California

Office of Civil Rights Civil Rights Coordinator
P.O. Box 997413, MS 0009 P.O. Box 989725
Sacramento, CA 95899-7413 West Sacramento, CA 95798-9725
Phone: 1-916-440-7370 Phone: 1-916-228-8764
(Ext. 711, CA State Relay) Fax: 1-916-228-8909
Email: [email protected] Email: [email protected]
Medi-Cal complaint forms are available at:
www.dhcs.ca.gov/Pages/Language.Access.aspx

You can also file a separate civil rights complaint with the federal Office for Civil Rights at the U.S.
Department of Health and Human Services. You can do this if you believe you have been discriminated
against on the basis of race, color, national origin, age, disability, or sex:

U.S. Department of Health and Human Services

Mail: 200 Independence Ave. SW Room 509F
HHH Building, Washington, DC 20201
Phone: 1-800-368-1019 (TTY: 1-800-537-7697)
Online Complaint Portal Assistant: https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Online Complaint forms: https://ocrportal.hhs.gov/ocr/cp/wizard_cp.jsf

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