Form MC14 A Qualified Medicare Beneficiary (Qmb), Specified Low-Income Medicare Beneficiary (Slmb), and Qualifying Individual (Qi) Application - California (Japanese)

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 Japanese. As of today, no separate filing guidelines for the form are provided by the issuing department.

FAQ

Q: What is Form MC14?
A: Form MC14 is an application for Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individual (QI) programs.

Q: What are QMB, SLMB, and QI programs?
A: QMB, SLMB, and QI are programs that help low-income individuals with Medicare coverage pay for their Medicare premiums, deductibles, and co-insurance.

Q: Who is eligible for QMB program?
A: Eligible individuals must have Medicare Part A, limited income, and few assets to qualify for the QMB program.

Q: Who is eligible for SLMB program?
A: Eligible individuals must have Medicare Part A, income slightly above the QMB program limits, and few assets to qualify for the SLMB program.

Q: Who is eligible for QI program?
A: Eligible individuals must have Medicare Part A, income slightly above the SLMB program limits, and few assets to qualify for the QI program.

Q: What does this application form require?
A: This application form requires personal and financial information, such as name, address, income, assets, and Medicare information.

Q: Do I need to provide proof of income and assets?
A: Yes, you need to provide proof of income and assets along with the application form to verify your eligibility for QMB, SLMB, or QI programs.

Q: Can I apply for multiple programs using this form?
A: Yes, you can apply for QMB, SLMB, and QI programs at the same time using this MC14 application form.

Q: What should I do if I need assistance with the application?
A: If you need assistance with filling out the application form, you can contact your local Social Security Administration office or the California Health Insurance Counseling and Advocacy Program for help.