Documents

” Medi-Cal 250% Program Employment Verification Form I, ____________________________________________________ the employer of the Medi-Cal beneficiary named_______________________________________________ Address_______________________________ City ______________ ZIP___ Case #\/SSN ________________ has been working for me since _____________ and each and every month thereafter and hereinafter for ____ hour a week, for a total compensation of $_____ a month performing the following work for me: EMPLOYER INFORMATION Employer name _________________________________________________________ Employer address _______________________________________________________ Date__________ Employer Signature _______________________________________ AUTHORIZATION RELEASE INFORMATION\/REPRESENTATION FORM I, ____________________________________________named below, or any other person\/attorney designated them to be my authorized representative, and to represent me, relative to my Medi—Cal benefits, or any other matter, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of any litigation. This authorization shall also be construed as an authorization to release any and all information to any person designated by the person mentioned below, including an attorney. Date: _______________ ___________________________________ _ Signature of Employee\/Medi-Cal Beneficiary Name of person\/organization being authorized Kevin Aslanian CCWRO, 1111 Howe Ave., Suite 635, Sacramento, CA 95825-8551 Tel. 916-712-0071 Email: [email protected] CCWRO 250% MC Work Verification Form 11-2020 Address: City: ZIP: Case SSN: has been working for me since: and every month thereafter and hereinafter for: undefined: a month performing the following work for me: Employer address: Date: Date_2: I: MediCal beneficiary named: ”

” Medi-Cal 250% Program Employment Verification This is to confirm that Name of Medi-Cal beneficiary SSN has been working for me commencing with and each month thereafter for date hours each week for $ a week for a total monthly sum of $ a month doing the following work for me: ________________________________ Specify type of work being done EMPLOYER NAME: ___ EMPLOYER ADDRESS: _____ DATE: ___________ EMPLOYER SIGNATURE: _________________________ Authorization to Release Information\/Representation Form I, , hereby authorize the person\/organization named herein, or any other person\/attorney designated them to be my authorized representative, and to represent me, relative to my Medi-Cal benefits, or any other matter, including the right to make statements on my behalf, or the filing for any fair hearing and the initiation of any litigation. This authorization shall also be construed as an authorization to release any and all information to any person designated by him, including an attorney. Dated: ___________________ ________________________________________ Signature of Medi-Cal Recipient\/Applicant Authorized Representative Name of Person and\/Organization Name Organization, if any Address Phone Number This is to confirm that: SSN 1: undefined: hours each week for: undefined_2: I: Name: Organization if any: Dated: Ca: Rec: entApp: cant: Address: Phone NumberRow1: SSN 2: SSN 24: 5: SSN 23r: ”