Eligibility Forms + Eligibility Manual

Most forms needed for the CMSP Program are included in the two eligibility determination systems – CalWIN and C-IV. The following form are provided as a supplement to those systems, when needed.

Form NumbersForm Title
CMSP Info Notice 1 (05/16)CMSP Benefits Summary
CMSP Info Notice 1 (SP) (05/16)Resumen de los Beneficios del CMSP
CMSP Info Notice 2 (05/16)CMSP Eligibility Summary
CMSP Info Notice 2 (SP) (05/16)Resumen de Requisitos Para el CMSP
CMSP 174 (06/09)CMSP Notice to Providers, Use of Medical Expenses to Reduce Excess Property
CMSP 201 (06/09)Requirement to Participate in Disability Evaluation Process
CMSP 201 (SP) (06/09)Requsio para participar en Procesamiento de Evaluación de Incapacitad
CMSP 202 (01/12)MedImpact Pharmacy Immediate Need
CMSP 203 (07/16)Other Health Care Coverage
CMSP 203 (SP) (07/16)Otro Alcance De Asistencia Médica
CMSP 205 (07/16)Third Party Liability Notification of Trust Cover Letter
CMSP 206 (06/06)CMSP Notice of Action, Denial of Benefits
CMSP 206 (SP) (06/06)Programa De Servicios Médicos De Los Condados Notice of Action, Denegación De Prestaciones
CMSP 208 (04/07)CMSP DDSD Application Checklist
CMSP 208A (04/07)CMSP DDSD Status Report
CMSP 211 (06/07)Notification of CMSP or Medi-Cal Eligibility Greater than 1 year
CMSP 215 (12/17)CMSP Supplemental Application
CMSP 215 (SP) (12/17)Programa de Servicios Médicos Del Condado (CMSP) Solicitud Complementaria
CMSP 216 (04/14)CMSP Telephonic Signature Declaration
CMSP 216 (SP) (04/14)Solicitud complementaria para el CMSP - Declaración de firma telefónica
CMSP 237 (12/16)Case Load Movement and Activity Report
CMSP 239 A (12/05)CMSP Notice of Action, Denial/Discontinuance of Benefits
CMSP 239 A (SP) (12/05)Programa De Servicios Médicos Del Condado Aviso De Acción, Negación/Descontinuación De Los Beneficios
CMSP 239 B (05/16)CMSP Notice of Action, Approval/Denial of Benefits
CMSP 239 B (SP) (05/16)Programa De Servicios Médicos Del Condado Aviso De Acción, Aprobación O Denegación De Prestaciones
CMSP 239 E (12/05)CMSP Notice of Action, Overpayment and Repayment Instructions
CMSP 239 E (SP) (12/05)Programa De Servicios Médicos Del Condado, Notificación De Acción Información De Sobrepago Y Reembolso
CMSP 239 F (05/16)CMSP Notice of Action, Aproval of Retroactive Benefits
CMSP 239 F (SP) (05/16)Programa De Servicios Médicos Del Condado, Notificación De Acción Aprobación De Beneficios Retroactivos
CMSP 239 G (05/16)CMSP Notice of Action, Denial of Retroactive Benefits
CMSP 239 G (SP) (05/16)Programa De Servicios Médicos Del Condado, Notificación De Acción Denegación De Beneficios Retroactivos
CMSP 239 P (05/16)CMSP Notice of Action, Approval/Denial of Benefits Restricted to Emergency Medical Services
CMSP 239 P (SP) (05/16)Programa De Servicios Médicos Del Condado Notificación De Acción, Aprobación O Denegación De Prestaciones Limitadas A Servicios Médicos De Emergencia
CMSP 239 R (06/09)CMSP Notice of Action, Discontinuance Notice--Deceased Persons
CMSP 239 R (SP) (06/09)Programa De Servicios Médicos Del Condado Aviso De Acción, Aviso De Descontinuación--Personas Fallecidas
CMSP 239 U (12/05)CMSP Notice of Action, Utilization of Property
CMSP 239 U (SP) (12/05)Programa De Servicios Médicos Del Condado, Aviso De Acción, Utilización De Bienes Inmuebles
CMSP 301 CIT (03/12)Proof of Citizenship Needed
CMSP 301 CIT (SP) (03/12)Prueba de Ciudadanía Necesaria
CMSP 301 CITID (03/12)Proof of Citizenship and Identity Needed
CMSP 301 CITID (SP) (03/12)Prueba de Ciudadanía y de Identificación Necesarias
CMSP 301 ID (03/12)Proof of Identity Needed
CMSP 301 ID (SP) (03/12)Prueba de Identidad Necesaria
CMSP 609 (07/16)County Request for CMSP Claims Detail
CMSP 610 (07/16)Claims Transmittal/Case Resolution
CMSP 1054 (06/09)Share-of-Cost Provider Letter
CMSP 1175 A (07/16)Benefit Appeals and Request for Medical Benefit Hearing By CMSP Governing Board
CMSP 1175 A (SP) (07/16)Apelaciones Y Solicitud De Audiencia Con La Junta Reguladora De CMSP Referente A Servicios Médicos
CMSP 1176 (07/16)Potential Third Party Liability Notification
CMSP 1176 (SP) (07/16)Notificación De Responsabilidad Potencial De Terceros
CMSP 1178 (04/15)Profit and Loss Statement
CMSP 1178 (SP) (04/15)Informe De Ganancias Y Pérdidas
CMSP 1179 (08/17)Eligibility Expenditure Report Fiscal Year 20__-20__
CMSP 1180 (12/17)Eligibility Expenditure Report Prior to Audit
CMSP NPP (07/16)CMSP Notice of Privacy Practices
CMSP NPP (SP) (07/16)CMSP Aviso De Prácticas De Privacidad
CMSP Denied Program Eligibility (05/17)CMSP Record of Denied Program Eligibility Form