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This version of the form is not currently in use and is provided for reference only. Download this version of
Form MC14 A
for the current year.
Form MC14 A Qualified Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individual (Qi) Application - California (Arabic)
This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California.
The document is provided in Arabic. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is MC14 A?
A: MC14 A is an application form for California residents to apply for Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) programs.
Q: Who is eligible to apply for QMB, SLMB, and QI programs?
A: California residents who meet certain income and asset requirements may be eligible to apply for QMB, SLMB, and QI programs.
Q: What are QMB, SLMB, and QI programs?
A: QMB, SLMB, and QI programs are assistance programs that help eligible individuals pay for Medicare premiums, deductibles, and coinsurance.
Q: What documents do I need to submit with MC14 A application?
A: You may need to provide proof of income, resources, citizenship or immigration status, and other supporting documents as requested on the application form.
Form Details:
- Released on March 1, 2021;
- The latest edition provided by the California Department of Health Care Services;
- Easy to use and ready to print;
- Available in Spanish;
- Quick to customize;
- Compatible with most PDF-viewing applications;
Download a fillable version of Form MC14 A by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.
Download Form MC14 A Qualified Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individual (Qi) Application - California (Arabic)
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