Forms
Most forms needed for the CMSP Program are included in the two eligibility determination systems – CalWIN and CalSAWS. The following form are provided as a supplement to those systems, when needed.
| Form Numbers | Form 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 (05/14) | 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 (10/21) | Profit and Loss Statement |
| CMSP 1178 (SP) (10/21) | Informe De Ganancias Y Pérdidas |
| CMSP Eligibility Expenditure Report | CMSP Eligibility Expenditure Report |
| 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 |
Eligibility Manual
Under the authority set forth in California law, the CMSP Governing Board sets the criteria for member participation in the County Medical Services Program. Eligibility for CMSP benefits is determined by the County Social Services Department in each participating CMSP county.
The CMSP Eligibility Manual addresses CMSP requirements such as residency, age limits, personal property limits, and motor vehicle limits. Additionally, the CMSP Eligibility Manual provides information on matters such as fair hearings, monthly share-of-cost, and aid-paid pending.
Download the most recent version of the CMSP Eligibility Manual here:
| Issue Date | Name | Effective For |
|---|---|---|
| 2020 05 18 | CMSP Eligibility Manual | |
| 2019 06 01 | CMSP Eligibility Manual | Beginning Dates of Aid from June 1, 2019 through March 26, 2020 |
| 2016 05 01 | CMSP Eligibility Manual | Beginning Dates of Aid from May 1, 2016 through May 31, 2019 |
To submit corrections or suggestions for the eligibility manual, please e-mail info@cmspcounties.org
Trainings
| Training Date | Training Slides | Link to Recording |
|---|---|---|
| 2022 11 02 | CMSP Eligibility Training |
CMSP Governing Board Office
1545 River Park Drive, Suite 435
Sacramento, CA 95815
1545 River Park Drive, Suite 435
Sacramento, CA 95815
