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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 Low-Income Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individuals (Qi) Application - California (Chinese)
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 Chinese. As of today, no separate filing guidelines for the form are provided by the issuing department.
FAQ
Q: What is the MC14 A form?
A: The MC14 A form is an application for Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI) programs.
Q: Who is eligible for QMB, SLMB, and QI programs?
A: These programs are for low-income individuals who meet certain income and resource requirements.
Q: What does QMB stand for?
A: QMB stands for Qualified Low-Income Medicare Beneficiary.
Q: What does SLMB stand for?
A: SLMB stands for Specified Low-Income Medicare Beneficiary.
Q: What does QI stand for?
A: QI stands for Qualifying Individual.
Q: What is the purpose of the QMB program?
A: The QMB program helps pay for Medicare Part A and Part B premiums, deductibles, coinsurance, and copayments for eligible low-income individuals.
Q: What is the purpose of the SLMB program?
A: The SLMB program helps pay for Medicare Part B premiums for eligible low-income individuals.
Q: What is the purpose of the QI program?
A: The QI program helps pay for Medicare Part B premiums for eligible low-income individuals.
Q: Is this form specific to California?
A: Yes, this form is specific to California.
Q: Is there a Chinese version of this form?
A: Yes, there is a Chinese version of this form available.
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 Low-Income Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individuals (Qi) Application - California (Chinese)
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