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Reminder: Instructions when Completing an MC 604 MDV Form

June 5, 2018

Providers should complete the Doctor’s Verification for Home and Community Based Services Under Spousal Impoverishment Provisions, also known as the Medi-Cal Doctor’s Verification form (MC 604 MDV), in a timely manner upon receipt from the county, patient or patient’s representative, in order to verify the nursing facility level of care that may allow a patient to qualify for in-home care and support services. To properly complete the form, providers must fill in the Doctor’s Information section of the form and submit the completed form to the county in the preaddressed envelope, if provided.

The MC 604 MDV form is used for Medi-Cal eligibility purposes and is separate from the assessment required by In-Home Support Services (IHSS) or other waiver programs.