Solicitation 017-926202-SL Social Services Agency

Transcripción

County of Orange
Bid 017-926202-SL
Solicitation 017-926202-SL
Social Services Agency Medi-Cal Annual Redetermination
Packets
Bid designation: Public
County of Orange
9/10/2013 5:46 PM
p. 1
County of Orange
Bid 017-926202-SL
Bid 017-926202-SL
Social Services Agency Medi-Cal Annual Redetermination Packets
Bid Number 017-926202-SL
Bid Title Social Services Agency Medi-Cal Annual Redetermination Packets
Bid Start Date
Sep 10, 2013 4:44:15 PM PDT
Bid End Date
Sep 13, 2013 1:00:00 PM PDT
Question & Answer
End Date
Sep 12, 2013 1:00:00 PM PDT
Bid Contact Sapreena L Leoso
714-567-7443
[email protected]
Contract Duration One Time Purchase
Contract Renewal Not Applicable
Prices Good for Not Applicable
Standard Disclaimer The County of Orange is not responsible for and accepts no liability for any technical
difficulties or failures that result from conducting business electronically.
Bid Comments
THE COUNTY OF ORANGE, COUNTY EXECUTIVE OFFICE - INFORMATION TECHNOLOGY (CEO-IT)/PUBLISHING
SERVICES DEPARTMENT IS SOLICITING BIDS FOR A ONE TIME PURCHASE AND DELIVERY CONTRACT FOR
PRINTING AND BINDERY OF TWO SOCIAL SERVICES AGENCY MEDI-CAL PACKETS;
PROJECT #1. MEDI-CAL ANNUAL REDETERMINATION PACKET (ENGLISH VERSION)
PROJECT #2. MEDI-CAL ANNUAL REDETERMINATION PACKET (SPANISH VERSION)
BASIS OF AWARD: ALL OR NONE
PLEASE SEE ATTACHED PRINTING SPECIFICATIONS (ATTACHMENT A) FOR DETAIL PROJECT INFORMATION.
ALL QUESTIONS PERTAINING TO THIS INVITATION FOR BID (IFB) MUST BE SUBMITTED THROUGH BIDSYNC ANY
COUNTY RESPONSE RELEVANT TO THIS IFB OTHER THAN THROUGH OR APPROVED BY CEO-IT/PURCHASING
DIVISION IS UNAUTHORIZED AND WILL BE CONSIDERED INVALID.
ALL BID RESPONSES SHALL BE SUBMITTED THROUGH BIDSYNC AND THE FOLLOWING MUST BE COMPLETED
IN ORDER FOR BID TO BE VALID;
1. COUNTY OF ORANGE COVER SHEET
2. SIGNATURE PAGE
3. COMPANY PROFILE
4. REFERENCES
5. CHILD SUPPORT ENFORCEMENT WEB FORM
6. BIDSYNC PRICING
ALL TWO PROJECTS MUST BE DELIVERED ON OR BEFORE SEPTEMBER 26, 2013 TO PUBLISHING SERVICES AT THE ADDRESS LISTED BELOW:
COUNTY OF ORANGE
CEO-IT/PUBLISHING SERVICES
ATTN: TBD
1300 S. GRAND AVE., BLDG. A
SANTA ANA, CA 92705
REFERENCE #: P1053345 - MC RRR ENGLISH/P1053346 - MC RRR SPANISH
THIS JOB WILL BE AWARDED SAME DAY BID IS CLOSED.
Item Response Form
Item 017-926202-SL-- 01-01 - MEDI-CAL ANNUAL REDETERMINATION FORMS (ENGLISH VERSION)
Quantity 25400 set
Unit Price Delivery Location County of Orange
025 - PUBLISHING SERVICES/PAPER
1300 S GRAND AVE
BLDG A
SANTA ANA CA 92705
9/10/2013 5:46 PM
Qty 25400
Description
p. 2
Delivery Location County of Orange
County of Orange
1300 S GRAND AVE
BLDG A
SANTA ANA CA 92705
Qty 25400
Bid 017-926202-SL
Description
MEDI-CAL ANNUAL REDETERMINATION PACKETS (ENGLISH VERSION)
Item 017-926202-SL-- 01-02 - MEDI-CAL ANNUAL REDETERMINATION FORMS (SPANISH VERSION)
Quantity 18150 set
Unit Price Delivery Location County of Orange
1300 S GRAND AVE
BLDG A
SANTA ANA CA 92705
Qty 18150
Description
MEDI-CAL ANNUAL REDETERMINATION PACKET (SPANISH VERSION)
9/10/2013 5:46 PM
p. 3
County of Orange
Bid 017-926202-SL
County of Orange – Bidder Instructions
1. DEFINITIONS:
a. "Bid" means an offer, made in response to a solicitation to perform a contract for work and labor or to supply goods or services at a
specified price, whether or not it is considered a "sealed bid" or results in award of a contract to a single or non-competitively bid
contract.
b. "Bidder" means a supplier who submits a bid to the County in response to a solicitation.
c. "Solicitation" means the process, by whatever name known or in whatever format used, of notifying prospective bidders that the
County wishes to receive bids for furnishing goods or services.
d. "Supplier" means a business entity, bidder, offeror, vendor or contractor.
e. "County" means the County of Orange.
2. SUBMISSION OF BIDS:
a. Bids must be hand delivered or sent via U.S. Mail or common carrier unless another method is specifically authorized in the solicitation.
b. Where a "sealed" bid is required, each bid shall be separately sealed inside an envelope and must be signed and received by the
closing time and date specified, and on the forms furnished by the County to be considered for award.
c. The bidder is solely responsible for ensuring that the full bid is received by the County in accordance with the solicitation requirements,
prior to the date and time specified in the solicitation, and at the place specified. The County shall not be responsible for any delays in
mail or by common carriers or by transmission errors or delays or misdelivery.
d. Bids received after the bid closing date and time will be considered nonresponsive.
e. If no time for receipt of bids is specified in the solicitation, the bid shall be due by the close of the business day on the date indicated.
Close of the business day shall be 5:00 p.m. All times are Pacific Standard Time (PST).
f. Generally, sealed bids will be opened and read on the due date unless another date and time is specified in the solicitation or any
addendum thereto or the reverse auction terms and conditions are included in the solicitation. When a County Agency/Department
facilitates a reverse auction, all bids shall remain confidential before and during the auction. Information is not public, including the
number and names of the responders, until the Notice of Intent to Award or contract award is published, whichever occurs first.
g. Faxed bid responses will NOT be allowed.
h. All bids received by the County and opened are subject to disclosure under the California Public Records Act, and other applicable law.
i. It is preferred that bids/proposals be submitted electronically at www.bidsync.com , unless otherwise stated in the bid packet. If
responding to this solicitation through BidSync, the electronic version of the bid response will prevail. The County of Orange is not
responsible for and accepts no liability for any technical problems that result from conducting business electronically.
j. The County shall not be liable for any expenses incurred by potential Bidders in the preparation or submission of their bids. The County
shall not, in an event, be liable for any pre-contractual expenses incurred by Bidders prior to the date of award and execution, if any,
of the Contract. Pre-contractual expenses are defined as expenses incurred by the Bidder in: a) preparing its bid in response to this
IFB; b) submitting that bid to the County; c) negotiating with the County any matter related to the Bidder's bid; and d) any other
expenses incurred by the Bidder prior to the date of award and execution, if any, of the Contract.
k. Bids are not to be marked as confidential or proprietary. The County shall refuse to consider any bid so marked. Additionally, all bids
shall become the property of the County. The County reserves the right to make use of any information or ideas in the bids submitted.
l. If clarification of this IFB is considered necessary, a written addendum shall be issued. Oral statement(s) concerning the meaning of
the contents of this IFB by County personnel or any other person is (are) unauthorized and should not be relied upon. All inquiries
concerning this IFB should be directed to the assigned DPA (Deputy Purchasing Agent) per the instructions in the IFB.
m. Bidders shall be solely responsible for any errors or omissions in their bids. Any discrepancies in numbers or calculations shall be
interpreted to reflect the lowest price to the County .
n. The Model Contract contained in this solicitation is the Contract proposed for execution. Negotiations may or may not be conducted with
the finalists; therefore, the response submitted should contain Offeror's most favorable terms and conditions, since the selection and
award may be made without further discussion. Any exceptions to the terms and conditions made by any Offeror after submission of
its response may result in elimination from further consideration .
o. Any exceptions to the County's terms and conditions must be clearly stated in responses to this solicitation. Any exception must
include the details of the exception and the reasons for it. The County reserves the right to disqualify vendors taking exception to its
terms and conditions. Vendors taking exception after notice of award will be disqualified from award of contract.
3. SOLICITATION ADDENDUM (ADDENDA):
a. The County of Orange does not guarantee that you will receive the addenda to this solicitation unless you received notification of this
solicitation by e-mail from BidSync on behalf of the County of Orange. Bidders registered on BidSync will receive an email notification
when an addendum has been created. A link to the County of Orange's online bidding web site can be found at:
http://egov.ocgov.com/ocgov/Procurement/Open%20Bids.
It is the Bidder's responsibility to request all additional information and/or modifications to this solicitation.
b. InPM
the event that the solicitation is revised by an addendum, supplier shall submit the original solicitation and any addenda that the buyer
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requires to be submitted.
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solicitation by e-mail from BidSync on behalf of the County of Orange. Bidders registered on BidSync will receive an email notification
when an addendum has been created. A link to the County
ofofOrange's
County
Orange online bidding web site can be found at:
Bid 017-926202-SL
http://egov.ocgov.com/ocgov/Procurement/Open%20Bids.
It is the Bidder's responsibility to request all additional information and/or modifications to this solicitation.
b. In the event that the solicitation is revised by an addendum, supplier shall submit the original solicitation and any addenda that the buyer
requires to be submitted.
c. Price(s) offered shall reflect all addenda issued by the County. Failure to do so will permit the County to interpret the bid to include all
addenda issued in any resulting contract.
4. PRICES:
a. All prices and notations must be typewritten.
b. All prices must be bid in U.S. currency.
c. Unit prices may not be more than four (4) places to the right of the decimal point. For example, a unit price of $.56726 each would
exceed this limitation. Unit prices which exceed this limitation will automatically be truncated to the fourth decimal place for both
evaluation and award purposes. Using the example just cited, the "6" at the end of the unit price would be truncated (i.e., dropped off)
leaving a unit price of $.5672 each.
d. An error in the bid may cause the rejection of that bid; however, the County may at its sole option retain the bid and make certain
arithmetic corrections. In determining if a correction will be made, the County will consider the conformance of the bid to the format and
content required by the solicitation, and any unusual complexity of the format and content required by the solicitation.
i. If the bidder's intent is clearly established based on review of the complete bid submittal, the County may at its sole option correct
an error based on that established intent.
ii. The County may at its sole option correct obvious clerical errors.
iii. The total price of unit-price items will be the product of the unit price and the quantity of the item. If the unit price is ambiguous,
unintelligible or uncertain for any cause, or is omitted, it shall be the amount obtained by dividing the "Extension" price by the
quantity of the item.
iv. Out of state contractors must include California Sales Tax permit number.
v. Prices quoted shall be firm for the first period of the price agreement.
vi. Cost increases may be considered during Contract renewal periods only. The County requires bona fide proof of cost increases
prior to any price escalation adjustment. A minimum of 30 (thirty) days advance notice in writing is required to secure such
adjustments. When offering escalating price bids, quote applicable labor and material separately as to percentage of total cost. No
retroactive pricing adjustments will be considered. The County may enforce, adjust, or cancel escalating price agreements as it
sees fit. The net dollar amount of profit will remain firm during the period of the price agreement. Adjustments increasing
Contractor's profit will not be allowed.
vii. All decreases will be automatically extended to the County
5. CASH DISCOUNTS: The County encourages bidders to offer cash discounts for prompt payment etc.; however, unless provided
elsewhere in the solicitation, cash discounts offered by bidders for the prompt payment of invoices will not be considered in evaluating
offers to determine the successful bidder for award of any resulting contract.
6. INSPECTION OF SOLICITATION DOCUMENTS: Supplier shall carefully review all documents referenced and made a part of this
solicitation to ensure that all information required to properly respond to the solicitation has been received or made available and all
requirements are priced in the bid. Failure to examine any document, drawing, specification, or instruction will be at the supplier's sole risk.
7. BRAND NAMES: Any reference to brand names and/or numbers in the solicitation is intended to be descriptive, but not restrictive, unless
otherwise specified. Bids offering equivalent items meeting the standards of quality specified may be considered, unless otherwise
specified, providing the bid clearly describes the article offered and how it differs from the referenced brand. Unless bidder specifies
otherwise, it is understood that the bidder is offering a referenced brand item as specified in the solicitation. The County reserves the right
to determine whether a substitute offer is equivalent to and meets the standards of quality indicated by the brand name references, and
the County may require the supply of additional descriptive material and a sample.
8. EVALUATION OF BIDS:
a. Where more than one line item is specified in the solicitation, the County reserves the right to determine the lowest, responsive and
responsible bidder, either on the basis of individual items, combination of items as specified in the solicitation, or on the basis of all
items included in the solicitation, unless otherwise expressly provided.
b. Unless otherwise specified in the solicitation, the County may accept any item or combination of items as specified in the solicitation, of
any bid unless the bidder expressly objects and conditions its response on receiving all items for which it provided a bid. In the event
that the bidder so objects, the County may consider the bidder's objection and evaluate whether the award on such basis will result in
the lowest price to the County or may determine in its sole discretion that such an objection is non-responsive and renders the bidder
ineligible for award.
c. All other criteria to be used in evaluating bids will be identified elsewhere in the solicitation.
9. CONFLICT OF INTEREST:
a. Current County Employees (PCC Section 10410):
i. No officer or employee shall engage in any employment, activity or enterprise from which the officer or employee receives
compensation or has a financial interest and which is sponsored or funded by any County Agency/Department, unless the
employment, activity or enterprise is required as a condition of regular County employment.
ii. No officer or employee shall contract on his or her own behalf as an independent contractor with any County agency to provide
goods or services.
b. Former County Employees (PCC Section 10411): For the two-year period from the date he or she left County employment, no former
County officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning,
arrangements or any part of the decision-making process relevant to the contract while employed in any capacity by any County
9/10/2013 5:46agency/department.
PM
c. For the twelve-month period from the date he or she left County employment, no former County officer or employee may enter into a
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ii. No officer or employee shall contract on his or her own behalf as an independent contractor with any County agency to provide
goods or services.
County
of Orange
Bidformer
017-926202-SL
b. Former County Employees (PCC Section 10411): For the
two-year
period from the date he or she left County employment, no
County officer or employee may enter into a contract in which he or she engaged in any of the negotiations, transactions, planning,
arrangements or any part of the decision-making process relevant to the contract while employed in any capacity by any County
agency/department.
c. For the twelve-month period from the date he or she left County employment, no former County officer or employee may enter into a
contract with any County agency/department if he or she was employed by that County agency in a policy-making position in the same
general subject area as the proposed contract within the twelve-month period prior to his or her leaving County service.
10. JOINT BIDS: Where two or more Suppliers desire to submit a single bid in response to a solicitation, they should do so on a
prime/subcontractor basis rather than as a joint venture. The County intends to contract with a single firm or multiple firms, but not with
multiple firms doing business as a joint venture.
11. SAMPLES TO DETERMINE RESPONSIVENESS TO TECHNICAL REQUIREMENTS FOR PURPOSES OF AWARD:
a. Samples of items, when required by the County, must be furnished free of expense to the County, unless otherwise provided.
b. Unless expressly set forth in the solicitation, the sample or samples furnished must be identical in all respects to the product or
products being offered to the County.
c. Bidders offering products of a different manufacturer and model number than those specified in the solicitation may be required to
submit samples for inspection and specification compliance testing in order for the County to determine if the item offered is equivalent
to and meets the minimum standards of quality acceptable to the County as indicated by the manufacturer and model number specified
in the solicitation.
d. Samples, if not destroyed by tests, may, upon request made at the time the sample is furnished, be returned at bidder's expense.
e. Samples may be required prior to award. If requested, such samples must be delivered to the address specified and within the
timeframe identified in the notification. Failure to submit samples as specified may be grounds for rejection.
12. SPECIFICATION CONCERNS:
a. In the event a supplier believes that the County's solicitation is unfairly restrictive, ambiguous, contains conflicting provisions or
mistakes or in the supplier's experience any resulting contract would be commercially impractical to perform, the matter should be
promptly brought to the attention of the buyer identified in the solicitation, in writing, immediately upon receipt of the solicitation, in order
that the matter may be fully considered and appropriate action taken by the County prior to the closing time set to receive bids.
13. VALIDITY OF BID: Unless specified elsewhere in the
solicitation, bidder's bid shall be valid for a minimum of one hundred eighty (180) days following the bid closing date.
14. MISTAKE IN BID: If prior to contract award, a bidder discovers a mistake in their bid which renders the bidder unwilling to perform under
any resulting contract, the bidder must immediately notify the buyer and request to withdraw the bid. It shall be solely within the County's
discretion as to whether withdrawal will be permitted. If the solicitation contemplated evaluation and award of "all or none" of the items,
then any withdrawal must be for the entire bid. If the solicitation provided for evaluation and award on a line item or combination of items
basis, the County may consider permitting withdrawal of specific line item(s) or combination of items.
15. COUNTY'S RIGHTS:
a. The County reserves the right to modify or cancel in whole or in part its solicitation at any time without prior notice.
b. The County reserves the right to reject any or all bids if the County determines that a bidder's bid was non-responsive to the solicitation
requirements and to waive informalities and minor irregularities in bids received.
c. The County reserves the right to reject any or all bids if the County determines that a bidder is not a responsible supplier.
d. Award final Contract with the lowest, responsive, responsible Bidder or Bidders as necessary to serve the best interests of the
County may require.
e. Award its total requirement to one Bidder or to apportion those requirements among two or more Bidders as the County may deem to be
in its best interests.
f. Make no guarantee as to the usage of the services by the County. The County furthermore makes no representation that any Contract
will be awarded to any Bidder responding to this IFB.'
g. All bids received may be public record after opening. Bids are not to be marked as confidential or proprietary. The County shall refuse
to consider any bid so marked. Bids must be submitted in response to this IFB may be subject to public disclosure as permitted by the
California Public Records Act. Additionally, all bids shall become the property of the County. The County reserves the right to make
use of any information or ideas in the bids submitted.
h. Waive, at its discretion, any irregularity or informality which the County deems correctable or otherwise not warranting rejection of the
bid.
i. Make final award determination based on the lowest responsive, responsible bid, but award will be contingent upon agency/department
approval, including a review of qualifications, and the successful bidder must have met all the qualifications/requirements set forth
herein.
16. UNFAIR PRACTICES ACT AND OTHER LAWS: Supplier warrants that its bid complies with the Unfair Practices Act (Business and
Professions Code Section 17000 et seq.) and all applicable County, State and Federal laws and regulations.
17. VIOLATION OF AIR OR WATER POLLUTION LAWS:
a. Prior to an award, the County shall ascertain if the intended awardee is a person included in notices from the Boards. In the event of
any doubt of the intended awardees' identity or status as a person who is in violation of any County, State, or federal air or water
pollution law, the County will notify the appropriate Board of the proposed award and afford the Board the opportunity to advise the
County that the intended awardee is such a person.
b. No award will be made to a person who is identified either by the published notices or by advice, as a person in violation of County,
State, or federal air or water pollution control laws.
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18. INDEPENDENCE OF BID: By submitting this bid, bidder swears under penalty of perjury that it did not conspire with any other supplier to
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a. Prior to an award, the County shall ascertain if the intended awardee is a person included in notices from the Boards. In the event of
any doubt of the intended awardees' identity or status as a person who is in violation of any County, State, or federal air or water
County
of proposed
Orange award and afford the Board the opportunity to advise
Bid 017-926202-SL
pollution law, the County will notify the appropriate Board
of the
the
County that the intended awardee is such a person.
b. No award will be made to a person who is identified either by the published notices or by advice, as a person in violation of County,
State, or federal air or water pollution control laws.
18. INDEPENDENCE OF BID: By submitting this bid, bidder swears under penalty of perjury that it did not conspire with any other supplier to
set prices in violation of anti-trust laws.
19. PROTESTS: All protests shall be submitted on protester's letterhead and include at minimum the following information:
á The name, address and telephone number of the protester;
á The signature of the protester or the protester's representative;
á The solicitation or contract number;
á A detailed statement of the legal and/or factual grounds for the protest; and
á The form of relief requested
All protests related to bid or proposal specifications must be submitted to the Deputy Purchasing Agent no later than five (5) business days
prior to the close of the bid or proposal. Protests received after the five (5) business day deadline will not be considered by the County. In
the event the protest of specifications is denied and the protester wishes to continue in the solicitation process, they must still submit a bid
prior to the close of the solicitation in accordance with the bid/proposal submittal procedures provided in the bid/proposal.
In protests related to the award of a contract , the protest must be submitted no later than five (5) business days after the notice of the
proposed contract award is provided by the Deputy Purchasing Agent. Protests relating to a proposed contract award which are
received after the five (5) business day deadline will not be considered by the County.
If the protester wishes to appeal the decision of the Deputy Purchasing Agent, the protester must submit, within three (3) business days
from receipt of the Deputy Purchasing Agent's decision, a written appeal to the Office of the County Purchasing Agent at:
1300 S. Grand Ave., Bldg A Santa Ana, CA 92705
The decision of the County Purchasing Agent on whether to allow the appeal to go forward will be final and there shall be no right to any
administrative appeals of this decision.
20. INDEPENDENT CONTRACTOR REPORTING REQUIREMENTS: Any independent contractor, prior to being awarded a purchase order
which contains services, must provide certain information pertaining to its business to the County. The County, in accordance with
Unemployment Insurance Code Section 1088.8, will report such information to the Employment Development Department. By submitting a
bid, bidder acknowledges this information is required and that it is being reported to the Employment Development Department.
Additional information on this reporting requirement can be found at the California Employment Development Department web site located
at www.edd.ca.gov/txicr.htm .
21. Orange County Child Support: To comply with the child support enforcement requirements of the County of Orange, within ten days of
notification of selection of award of contract but prior to official award of contract, the selected contractor agrees to furnish to the
contract administrator, the Purchasing Agent, or the agency/department deputy purchasing agent:
a. In the case of an individual contractor, his/her name, date of birth, Social Security number, and residence address;
b. In the case of a contractor doing business in a form other than as an individual, the name, date of birth, Social Security number, and
residence address of each individual who owns an interest of ten (10) percent or more in the contracting entity;
c. A certification that the contractor has fully complied with all applicable federal and state reporting requirements regarding its
employees; and
d. A certification that the contractor has fully complied with all lawfully served Wage and Earnings Assignment Orders and Notices of
Assignment and will continue to so comply.
Failure of the contractor to timely submit the data and/or certifications required may result in the contract being awarded to another
contractor. In the event a contract has been issued, failure of the contractor to comply with all federal, state, and local reporting
requirements for child support enforcement or to comply with all lawfully served Wage and Earnings Assignment Orders and Notices of
Assignment shall constitute a material breach of the contract. Failure to cure such breach within 60 calendar days of notice from the
County shall constitute grounds for termination of the contract.
22. AMERICANS WITH DISABILITY ACT (ADA): To comply with the non-discrimination requirements of the ADA, it is the policy of the County
to make every effort to ensure that its programs, activities and services are available to all persons, including persons with disabilities. For
persons with a disability needing a reasonable modification to participate in the procurement process, or for persons having questions
regarding reasonable modifications for the procurement process, you may contact the buyer listed in the solicitation.
23. Vendor Advisory: The County does not require and neither encourages nor discourages the use of lobbyists or other consultants for
the purpose of securing business.
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County of Orange
Bid 017-926202-SL
http://egov
.ocgov.co
m/vgnfiles/
ocgov/OC
GOVPortal/
Branding/a
COUNTY OF ORANGE
DEPT
SOLICITATION NUMBER:
017-926202 -SL
FOR:
Social Services Agency Medi-Cal Annual Redetermination Packets
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p. 8
County of Orange
Bid 017-926202-SL
Signature Page
I have read and understand and agree to the terms and conditions herewith and I am submitting a
response to this solicitation .
b
c
d
e
f
g
Date:
Company Name:
* Authorized Signature
Print Name
Title
Print Name
Title
OR
I prefer not to submit a bid in response to this solicitation per the reason(s) given below.
Reason(s):
aaa
Date:
Company
Name:
Print Name
Title
* If the Contractor is a corporation, signatures of two specific corporate officers are required as further
set forth.
The first corporate officer signature must be one of the following:1) the Chairman of the Board; 2) the
President; 3) any Vice President.
The second corporate officer signature must be one of the following: a) Secretary; b) Assistant
Secretary; c) Chief Financial Officer; d) Assistant Treasurer.
In the alternative, a single corporate signature is acceptable when accompanied by a corporate
resolution demonstrating the legal authority of the signature to bind the company.
RETURN THIS SHEET WITH YOUR RESPONSE
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p. 9
County of Orange
Bid 017-926202-SL
Part 2:
Company Profile
(Complete this form and submit as Part 2 in second tabbed section of response)
Company Legal Name:
Business Address:
Address for mailed funds:
Telephone Number: (
)
Facsimile Number: (
)
Email Address:
Length of time the firm has been in business:
Length of time at current location:
Is your firm a sole proprietor doing business under a different name:
b Yes
c
d
e
f
g
b No
c
d
e
f
g
If yes, please indicate sole proprietor's name and the name you are doing business under:
Federal Taxpayer ID Number
Is your firm incorporated: g
b Yes
c
d
e
f
b No
c
d
e
f
g
State of Incorporation:
Regular business hours:
Regular holidays and hours when business is closed:
Contact person in reference to this request for RFP solicitation:
Telephone Number: (
)
Facsimile Number: (
)
Email Address:
Name of administrator to who questions regarding accounts payable should be directed:
Telephone Number: (
)
Facsimile Number: (
)
Email Address:
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p. 10
County of Orange
Bid 017-926202-SL
EXHIBIT B
References
All Bidders must provide a minimum of three (3) Letters of Reference. The references should be from clients who
are comparable in scope to the County of Orange. Include one reference from a governmental agency. References
must cover services performed by your company in the past five (5) years. At least one of the references must cover
services performed in the past year. Services should be similar to those services required in this solicitation.
Additionally, please complete the form below on the clients who have provided references:
References must include the name and address of the company or governmental agency and the name and telephone
and facsimile numbers of contact person(s), annual agreement dollar amount of the Contract, and a brief description of
the agreement/Contract work and services provided. Attach additional sheets if necessary.
1.
Name of Reference:
Address:
Contact Name:
Telephone Number:
Annual agreement dollar amount:
Facsimile Number:
Brief Description of agreement/Contract work or services provided:
5
6
2.
Name of Reference:
Address:
Contact Name:
Telephone Number:
Facsimile Number:
5
6
3.
Name of Reference:
Address:
Contact Name:
Telephone Number:
Facsimile Number:
5
6
9/10/2013 5:46 PM
p. 11
County of Orange
Bid 017-926202-SL
County of Orange Child Support Enforcement
Certification Requirements
(blank form)
A.
In the case of an individual Contractor, his/her name, date of birth, Social Security number, and residence
address:
Name:
D.O.B:
Social Security No:
Residence Address:
B.
In the case of a Contractor doing business in a form other than as an individual, the name, date of birth, Social
Security number, and residence address of each individual who owns an interest of ten (10) percent or more in
the contracting entity:
Name:
D.O.B:
Social Security No:
Residence Address:
Name:
D.O.B:
Social Security No:
Residence Address:
Name:
D.O.B:
Social Security No:
Residence Address:
(Additional sheets may be used if necessary)
C.
A certification that the Contractor has fully complied with all applicable federal and state reporting requirements
regarding its employees; and
D.
A certification that the Contractor has fully complied with all lawfully served Wage and Earnings Assignment
Orders and Notices of Assignment and will continue to so comply.
"I certify that
is in full compliance with all
applicable federal and state reporting requirements regarding its employees and with all lawfully served
Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in
9/10/2013 5:46
PM
compliance
throughout the term of Contract
with the County of
p. 12
County of Orange
Bid 017-926202-SL
(Additional sheets may be used if necessary)
C.
A certification that the Contractor has fully complied with all applicable federal and state reporting requirements
regarding its employees; and
D.
A certification that the Contractor has fully complied with all lawfully served Wage and Earnings Assignment
Orders and Notices of Assignment and will continue to so comply.
"I certify that
is in full compliance with all
applicable federal and state reporting requirements regarding its employees and with all lawfully served
Wage and Earnings Assignment Orders and Notices of Assignments and will continue to be in
compliance throughout the term of Contract
with the County of
Orange. I understand that failure to comply shall constitute a material breach of the Contract and that
failure to cure such breach within ten (10) calendar days of notice from the County shall constitute
grounds for termination of the Contract.
Authorized Signature
9/10/2013 5:46 PM
Print Name
Title
p. 13
County of Orange
Bid 017-926202-SL
ATTACHMENT A
SCOPE OF WORK
I.
II.
THIS IS A ONE TIME PURCHASE FOR THE PRINTING AND DELIVERY OF TWO
SOCIAL SERVICES AGENCY MEDI-CAL ANNUAL REDETERMINATION PACKETS AS
LISTED:
1.
PROJECT #1. MEDI-CAL ANNUAL REDETERMINATION (ENGLISH
VERSION) – 25,400 SETS
2.
PROJECT #2. PROJECT #1. MEDI-CAL ANNUAL REDETERMINATION
(SPANISH VERSION) – 18,150 SETS
ALL TWO PROJECTS MUST BE DELIVERED TO PUBLISHING SERVICES
DEPARTMENT ON OR BEFORE SEPTEMBER 26, 2013, AT 3:30 P.M. (PACIFIC TIME)
AT THE ADDRESS LISTED BELOW:
CEO-IT/PUBLISHING SERVICES
1300 S. GRAND AVE. BLDG. A
SANTA ANA, CA 92705
REFERENCE: P1053345 –MC RRR ENGLISH/P1053346 – MC RRR
SPANISH
ATTN: TBD
PHONE: TBD
EMAIL: TBD
III.
PROJECT COUNTY CONTACT:
ATTN: TBD
PHONE: TBD
EMAIL: TBD
BLDG. A, 1ST FLOOR
SANTA ANA, CA 92705
COUNTY PURCHASING CONTACT:
SAPREENA LEOSO
CEO/IT PURCHASING DIVISION
1501 E. ST. ANDREW PLACE
SANTA ANA, CA 92705
PHONE: 714-567-7443
FAX: 714-560-4565
EMAIL: [email protected]
IV.
CONTRACTOR INFORMATION:
(TBD)
Attachments A & B
9/10/2013 5:46 PM
Page 1
p. 14
County of Orange
V.
Bid 017-926202-SL
DETAILED DESCRIPTION OF WORK TO BE PERFORMED BY CONTRACTOR AS
LISTED UNDER EACH PRINTING SPECIFICATION ATTACHMENT AND ALSO IN THIS
SCOPE OF WORK:
1. FILES FOR EACH PROJECT HAVE BEEN ATTACHED SEPARATE, PLEASE
REVIEW FOR MORE INFORMATION ON PRINTING DETAILS.
2. VENDOR SHALL BE RESPONSIBLE FOR THE PICK UP OF VOTER FORMS
AND LABELS FROM PUBLISHING SERVICES ADDRESS.
3. CONTRACTOR WILL BE PROVIDED WITH SPECIAL BOX LABELS FOR
EACH PRINTING PROJECT.
4. NO UNDERRUNS ALLOWED
5. OVERRUNS WILL BE PAID IF APPROVED BY COUNTY OF ORANGE
BUYER.
6. COUNTY MUST RECEIVE MEDI-CAL PACKETS BY OR BEFORE
SEPTEMBER 26, 2013.
7. ANY CHANGES OR CORRECTIONS MUST BE VERIFIED IN WRITING TO
CONTRACTOR BY PURCHASING.
8. FREIGHT MUST BE INCLUDED IN BID PRICE OR VENDOR MAY LIST AS
ADDITIONAL ITEM.
CONTRACTOR REQUIRED TO RETURN PRODUCED OR PROVIDED ARTWORK WITH
REVISIONS TO DEPARTMENT WITH COMPLETED JOB. FAILURE TO COMPLY
COULD RESULT IN DISQUALIFICATION AS A CONTRACTOR.
ALL WORK PROPOSED UNDER THIS CONTRACT/AGREEMENT/BID/PRUCHASE
ORDER, INCLUDING ALL WORK PROPOSED BY SUBCONTRACTORS AND
SUPPLIERS, WILL BE PERFORMED WITHIN THE UNITED STATES. THE
CONTRACTOR, INCLUDING SUBCONTRACTORS AND SUPPLIERS, AGREE NOT TO
CONDUCT OR CONTRACT FOR ANY WORK ON THIS
CONTRACT/AGREEMENT/BID/PURCHASE ORDER OUTSIDE THE UNITED STATES
AFTER THE COUNTY APPROVAL WITHOUT THE PRIOR, EXPRESSED, WRITTEN
APPROVAL OF THE DIRECTOR, COUNTY EXECUTIVE OFFICE.
CEO/IT REGULAR BUSINESS HOURS ARE 8:00 A.M. TO 5:00 P.M., MONDAY
THROUGH FRIDAY.
Attachments A & B
9/10/2013 5:46 PM
Page 2
p. 15
County of Orange
Attachments A & B
9/10/2013 5:46 PM
Bid 017-926202-SL
Page 3
p. 16
County of Orange
Attachments A & B
9/10/2013 5:46 PM
Bid 017-926202-SL
Page 4
p. 17
County of Orange
Bid 017-926202-SL
ATTACHMENT B
COMPENSATION AND PRICING PROVISIONS
This is a fixed fee Contract between the County and Contractor for goods and services provided in Attachment A,
Scope of Work. The Contractor agrees to accept the specified compensation as set forth in this Contract as full
remuneration for services.
1. Pricing
Pricing set forth in this Attachment shall be firm for the term of the Contract. All price decreases will
automatically be extended to the County of Orange. County will accept decrease only, Pricing below will be
firm unless a reduction is available.
Description
Quantity
Unit
Unit Price
Total Price
MEDI-CAL ANNUAL
REDETERMINATION
(ENGLISH VERSION)
25,400
Sets
$__________
$__________
MEDI-CAL ANNUAL
REDETERMINATION
(SPANISH VERSION)
18,150
Sets
$__________
$__________
Subtotal $__________
Sales Tax $__________
Total Amount Due $__________
2. Payment Terms
Contractor shall reference Contract number on invoice. Payment will be net 30 days after receipt of an
invoice in a format acceptable to the County of Orange and verified and approved by the agency/department
and subject to routine processing requirements. The responsibility for providing an acceptable invoice rests
with the Contractor.
Billing shall cover services and/or goods not previously invoiced. The Contractor shall reimburse the County
of Orange for any monies paid to the Contractor for goods or services not provided or when goods or services
do not meet the Contract requirements. Payments made by the County shall not preclude the right of the
County from thereafter disputing any items or services involved or billed under this Contract and shall not be
construed as acceptance of any part of the goods or services.
3. Invoicing Instructions:
Invoices and support documentation are to be sent to:
County of Orange
CEO/Information Technology
1501 E. St. Andrew Place, Suite 200
Santa Ana, CA 92705
Attn: Accounts Payable
Contractor will provide an invoice for services rendered, not more frequently than annually. Each invoice
will have a number and shall include the following information:
1. Contractor’s name and address
2. Contractor’s remittance address
3. County Contract number
4. Contractor’s Federal I.D. number
Attachments A & B
9/10/2013 5:46 PM
Page 5
p. 18
County of Orange
5.
6.
7.
8.
Bid 017-926202-SL
Date of Order
Product/service description, quantity, prices
Sales tax, if applicable
Total invoice amount
The responsibility for providing an acceptable invoice to the County for payment rests with the Contractor.
Incomplete or incorrect invoices are not acceptable and shall be returned to the Contractor for correction.
Attachments A & B
9/10/2013 5:46 PM
Page 6
p. 19
County of Orange
Bid 017-926202-SL
Medi-Cal Annual Redetermination Packet
Please complete and return the enclosed Client Action Forms in the
enclosed postage paid envelope.
Your Medi-Cal worker will contact you if additional
verifications are required.
Items
Returned
Medi-Cal RRR Forms (English)
Forms to Return
Medi-Cal Annual Redetermination Form
Important Information For Persons Requesting
Medi-Cal
MC 210 RV (05/11)
Property Supplement
MC 210 PS (05/07)
Would You Like To Register To Vote?
NVRA Voter Preference
Form (01/13)
California Voter Registration Form
No Form #
MC 219 (4/10)
Informing Notices
Breast and Cervical Cancer Treatment
MC Info Notice 372
Program (BCCTP)
(09/09)
Language Service Notice
MC 4034 (01/08)
Your Rights
PUB 13 (06/11)
Medical and Dental Health Check Ups
Medi-Cal Services for Children and Young
People
Council on Aging - Orange County (HICAP)
Medicare Recipients Who Need Help Filling
Out Medi-Cal Paperwork
PUB 183 (English 06/04)
MC 003 (11/12)
No Form #
Medi-Cal RRR Cover Letter – English - 7/1/13
9/10/2013 5:46 PM
p. 20
County of Orange
Bid 017-926202-SL
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Bid 017-926202-SL
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County of Orange
Bid 017-926202-SL
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Bid 017-926202-SL
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9/10/2013
5:46 PM
p. 24
State of California Health and Human Services Agency
County of Orange
Bid 017-926202-SL
Department of Health Care Services
Important Information for Persons
Requesting Medi-Cal
Privacy and Confidentiality
Notification
Sections 14011 and 14012 of the Welfare and
Institutions Code allow the local social services
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p. 25
County of Orange
Bid 017-926202-SL
I Have The Right To: continued from page 1
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-29/10/2013 5:46 PM
MC 219 (4/10)
p. 26
County of Orange
Bid 017-926202-SL
I Have The Responsibility To Tell My
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Days Whenever:
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MC 219 (4/10) English
9/10/2013 5:46 PM
-3p. 27
County of Orange
Bid 017-926202-SL
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-49/10/2013 5:46 PM
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MC 219 (4/10)
p. 28
County of Orange
Bid 017-926202-SL
I Understand That:
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MC 219 (4/10) English
9/10/2013 5:46 PM
-5p. 29
County of Orange
Bid 017-926202-SL
I Understand That: continued from page 5
16.After my death, the State has the right to seek
reimbursement from my estate for all MediCal benefits I received after age 55 unless I
have a surviving spouse or registered domestic
partner (during his or her lifetime), minor
children, blind or permanently and totally
disabled children, or it would create a hardship
for my heirs.
17.After the death of my surviving spouse or
registered domestic partner, the State has
the right to claim from the part of his or her
estate received from me, all Medi-Cal benefits
I received after age 55 up to the amount of
property my spouse or registered domestic
partner received from my estate.
-69/10/2013 5:46 PM
MC 219 (4/10)
p. 30
County of Orange
Bid 017-926202-SL
(Keep for your records) I hereby state that I have reviewed the information on this form with a
county representative and that I fully understand my Rights and Resposibilities to have my eligibility
determined for Medi-Cal and to maintain that eligibility.
ApplicantL8tive Signature(opcional)
Date
County Use Section
I!')(TIn Person T#
?
F)M5'( F)
.
Eligibility Worker’s Signature
$"B'6L"D(English
9/10/2013 5:46 PM
-7p. 31
County of Orange
State of California—Health and Human Services Agency
Bid 017-926202-SL
Case name: _________________________________________
Worker’s name: ______________________________________
Worker’s telephone number: ____________________________
PROPERTY SUPPLEMENT
STOP: If you are applying for no-cost Medi-Cal only for children under age 19 and/or pregnant
women applying only for pregnancy-related services, you do not need to complete this form. You
may be contacted later if necessary.
GO: If you are applying for full-coverage Medi-Cal for a family including adults, please complete this
form and be sure to list all your property. The county worker will determine which properties are
important to your application. If you have any questions, please contact your worker. Note: Owning
a home does not make you ineligible for Medi-Cal.
Mark the box under YES or NO for each item held in the name of, or held for the benefit of any family
member in the home. Please follow the instruction below each question.
YES
1.
NO
ITEM
Shares of stock or mutual funds.
If yes, please provide a copy of the stock or mutual fund certificates indicating the number of
shares.
2. Individual Retirement Accounts (IRAs), Keoghs, or work-related pension funds.
If yes, please provide the most recent statements from your employer, financial institution, or
brokerage indicating the amount of principal and interest you are receiving or the cash value
(after penalties for early withdrawal).
3. Annuities, burial trusts, burial contracts or burial insurance, trusts or agreements
where money or property is held for the benefit of any family member in the
home, blocked accounts, court-ordered settlements, judgments, orders for
support, prenuptial and post-nuptial agreements, promissory notes, mortgages,
deeds of trust, etc.
If yes, please provide copies of the policies, contracts, trusts, purchase agreements, court orders,
account documents showing investments and distributions.
4.
Business accounts and property.
If yes, please provide tax returns, invoices, receipts, licenses, profit and loss statements, etc.
5. House, condominium, ranch, land, mobile home, or life estate that is your home
that you live in, or that is your former home and is lived in by your spouse, child
under 21, disabled son or daughter, dependent relative, or a sibling who lived in
the property continuously and provided care for one year which enabled you to
remain in the home rather than a nursing facility.
If yes, please list address of property here: ___________________________________________
No verification is required.
6. If you own a home or former home and you are absent for any reason (including
admission into long-term care) but intend to return home someday, please
indicate below. NOTE: The word “intend” means “desire or wish” to return home
even though you may not be physically or mentally able to do so.
Page 1 of 3
MC 210 PS (05/07)
9/10/2013 5:46 PM
p. 32
County of Orange
Bid 017-926202-SL
Yes, I intend to return home someday. No, I do not intend to return home someday.
Please list the address of the property here: __________________________________________
No verification is required if you answered that you do intend to return home someday. If you
answered that you do NOT intend to return someday, please submit a copy of the most recent tax
assessment. If you choose to, you may provide an appraisal from a qualified real estate
appraiser and that value will be used if it is lower.
7. Other real estate, condominiums, buildings, mobile homes, life estates, time
shares, oil and mineral rights.
If yes, please provide copies of the mortgage papers, most recent tax assessment, registration, or
ownership documents.
8.
Motorcycles, trailers, boats, or other motorized vehicles that are not used by you
as a home.
Please provide a copy of the ownership documents or most recent registrations, purchase
agreements, sales receipts, or estimates of value from a qualified source. On the submitted verification for each item, indicate if the item is used: O on the job (such as a taxi); O to travel long distances to work (such as a truck used by a contractor working out of town); O to carry the main supply of fuel or water for your home; O to transport a disabled or incapacitated family member living in the home or if it is business property.
9.
Jewelry (not wedding rings, engagement rings, or heirlooms) worth more than
$100.00.
If yes, please provide copies of sales receipts, appraisals, estimates of value or insurance
documents.
10. Any other real or personal property, assets, or resources valued at $500 or more.
If yes, send copies verifying the property and its worth.
11. Has anyone spent or used any of the items listed above in payment for, or as
security for medical services?
If yes, please explain below and attach verifications.
1 through 10. If you owe money on any of the items listed above, or if any of the items
listed above have liens against them, please provide copies of the lien,
loan, or security documents.
12.
Did you, or any family member in the home, sell or give away any money or
property in the past
O 36 months (or 60 months if the transfer was made to or from a trust or
agreement for holding money or property for the benefit of someone) if you are
applying for Medi-Cal; or
O 12 months if you are currently receiving Medi-Cal? If yes, please explain in the “Additional Information” section at the end of this form and attach
verifications.
The following questions apply only to those individuals who are already receiving Medi-Cal.
13.
Does any family member in the home have a checking account or savings
account?
If yes, send copies of account statements showing current balances in the accounts.
Page 2 of 3
MC 210 PS (05/07)
9/10/2013 5:46 PM
p. 33
County of Orange
14.
Bid 017-926202-SL
Does anyone have a court-ordered settlement or judgment? If yes, send copies of all court orders, documents, and agreements. If copies have already been
provided to your worker, you do not need to provide them again. 15.
Does anyone have life insurance or long-term care insurance?
If yes, send copies of your policies, contracts, and purchase agreements. If copies have already
been provided to your worker, you do not need to provide them again. If your policy is a certified
California Partnership for Long-term Care policy, send a copy of your most recent benefit
statement.
Additional information:
Page 3 of 3
MC 210 PS (05/07)
9/10/2013 5:46 PM
p. 34
County of Orange
Bid 017-926202-SL
If you are not registered to vote where you live now, would you like to apply to register to vote here today?
(Check One)
Already registered. I am registered to vote at my current residence address.
Yes.
I would like to register to vote. (Please fill out the attached voter registration form.)
No.
I do not want to register to vote.
NOTE: IF YOU DO NOT CHECK A BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO
VOTE AT THIS TIME. YOU MAY TAKE THE ATTACHED VOTER REGISTRATION FORM TO REGISTER AT
YOUR CONVENIENCE.
___________________________________________________________________
Applicant Name
Date
Important Notices
1. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this
agency.
2. If you would like help in filling out the voter registration form, we will help you. The decision whether to seek or accept help
is yours. You may fill out the voter registration form in private.
3. If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in
deciding whether to register or in applying to register to vote, or your right to choose your own political party preference or
other political preference, you may file a complaint with the Secretary of State by calling toll-free
(800) 345-VOTE (8683)
or you may write to: Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. For more information on elections and
voting, please visit the Secretary of State’s website at www.sos.ca.gov.
01/13 NVRA Voter Preference Form
9/10/2013 5:46 PM
p. 35
County of Orange
State of California – Health and Human Services Agency
Bid 017-926202-SL
BREAST AND CERVICAL CANCER TREATMENT PROGRAM (BCCTP)
The BCCTP may provide Medi-Cal to low-income people that live in California and have
breast and/or cervical cancer.
If you have been denied Medi-Cal or you are no longer eligible for Medi-Cal through
your county and you have breast and/or cervical cancer, tell your county Eligibility
Worker (EW). Your EW can make a referral for you to the BCCTP.
An Eligibility Specialist (ES) from the BCCTP will call or write to you for more
information. The requested information will help us to see if you are eligible for the
program. You may be Medi-Cal eligible through the BCCTP if you are a woman and
you meet the following requirements:






Have been screened and found in need of treatment for breast and/or cervical
cancer, follow-up care for cancer, or precancerous cervical lesions/conditions by
an Every Woman Counts (EWC) or Family Planning, Access, Care and
Treatment (FamPACT) provider; and
Are a California resident; and
Are under age 65; and
Are a United States citizen or have satisfactory immigration status; and
Have no other health insurance including full-scope no share-of-cost Medi-Cal, or
Medicare; and
Have a monthly gross family income, at the time of screening and diagnosis, that
is at or below 200 percent of the federal poverty level.
If you have been screened for breast and/or cervical cancer by a provider that is not
with EWC or FamPACT, you can still be referred to the BCCTP. Your BCCTP worker
will help you find an EWC or FamPACT provider that can confirm your diagnosis.
Even if you do not meet all the above requirements, you may still receive BCCTP
through the State-funded BCCTP. The State-funded BCCTP can help you for up to18
months for breast cancer or up to 24 months for cervical cancer. The State-funded
BCCTP is available to men and women, regardless of immigration status.
For additional information or questions on the BCCTP, call 1-800-824-0088
MC Info Notice 372 (09/09)
9/10/2013 5:46 PM
p. 36
County of Orange
9/10/2013 5:46 PM
Bid 017-926202-SL
p. 37
County of Orange
Bid 017-926202-SL
Language Services Notice
If you do not understand this information or notification, call your county Medi-Cal worker.
You have the right to interpreter services provided by the county at no cost to you.
Si no entiende esta información o notificación, llame al trabajador de Medi-Cal de su condado.
Tiene derecho a obtener servicios de intérpretes proporcionados por el condado sin costo para Ud.
(Spanish)
‫ ﻟﺪﻳﻚ ﺣﻖ اﳊﺼﻮل ﻋﻠﻰ ﺧﺪﻣﺎت‬.‫ اﳋﺎص ﲟﻘﺎﻃﻌﺘﻚ‬Medi-Cal ‫ إﺗﺼﻞ ﲟﻮﻇﻒ‬، ‫إذا ﻟﻢ ﺗﻔﻬﻢ ﻫﺬه اﳌﻌﻠﻮﻣﺎت أو ﻫﺬا اﻹﺑﻼغ‬
(Arabic) .‫ﺗﺮﺟﻤﺔ ﻣﺠﺎﻧﻴﺔ ﻣﺘﻮﻓﺮة ﻟﻚ ﻣﻦ ﻗِﺒﻞ اﳌﻘﺎﻃﻌﺔ‬
如果您不理解此處的資訊或通知,請電洽您所在縣的Medi-Cal工作人員。您有權免費獲得縣政府
提供的免費口譯服務。 (Chinese)
‫ ﺷﻤﺎ اﻳﻦ ﺣﻖ را دارﻳﺪ ﻛﻪ‬.‫ ﻛﺎﻧﺘﻲ ﺧﻮد ﲤﺎس ﺑﮕﻴﺮﻳﺪ‬Medi-Cal ‫ ﺑﺎ ﻣﺪدﻛﺎر‬،‫اﮔﺮ اﻳﻦ اﻃﻼﻋﺎت و ﻳﺎ اﻃﻼﻋﻴﻪ را درك ﳕﻲ ﻛﻨﻴﺪ‬
(Farsi) .‫ﺑﻪ ﻃﻮر راﻳﮕﺎن از ﺧﺪﻣﺎت ﻣﺘﺮﺟﻢ از ﻃﺮﻳﻖ ﻛﺎﻧﺘﻲ اﺳﺘﻔﺎده ﻛﻨﻴﺪ‬
Yog koj tsis totaub txog cov kev qhia lossis tsab ntawv no, hu rau koj tus neeg tuav ntaub ntawv
Medi-Cal hauv lub county. Koj muaj cai tau txais kev pab txhais lus dawb los ntawm lub county.
(Hmong)
‫҆܄@ێ‬Ǧ@ࣃ‫ݖ‬Էθ@‫ێ‬६०@ր@‫ؾ‬ɜ@Ĉ‫مڐ‬ɜ@ࠥ‫@ࣲڒ‬mMc@ɽʁ@‫مڜݗ‬ö@‫۾‬টॣֲ֫٤N@
Ãۖۜɜ@ࠥ‫ࣲڒ‬Ã@ЛΕ΂@‫܆‬Ěॣɜ@ࣃَ@Էҿ֢θ@ю‫@ڽ‬ŇπÃ@ۘ֨ɩɳN (Korean)
Если вы не понимаете данную информацию или уведомление, позвоните сотруднику
компании Medi-Cal вашего округа. У вас есть право на получение услуг переводчика,
которые предоставляются округом бесплатно. (Russian)
Kung hindi ninyo naiintindihan ang impormasyon o paunawang ito, tawagan ang inyong manggagawa
sa Medi-Cal ng county. Kayo ay may karapatang magkaroon ng mga serbisyo ng tagasalin na ibibigay
ng county na walang bayad sa inyo. (Tagalog)
Neáu quyù vò khoâng hieåu chi tieát hoaëc thoâng baùo naøy, haõy ñieän thoaïi cho nhaân vieân Medi-Cal taïi
quaän quyù vò. Quyù vò coù quyeàn ñöôïc quaän cung caáp dòch vuï thoâng dòch mieãn phí cho quyù vò.
(Vietnamese)
MC 4034 (01/08)
9/10/2013 5:46 PM
p. 38
County of Orange
9/10/2013 5:46 PM
Bid 017-926202-SL
p. 39
■
■
■
■
You cannot get your wheelchair into
examination, interview rooms or restrooms.
Men get referred to job training for better
paying jobs than women.
The county does not want you to have training
because they say you are “too old.”
You are not allowed to adopt a baby because you
are of a different race.
DISCRIMINATION COMPLAINTS
If you think you have been discriminated against, you may
submit a complaint application separately to the County
or the State, and the Federal Government. The Federal
agency that you must complain to depends on which
program your complaint is about.
You can file a discrimination complaint with:
1. FOR ALL PROGRAMS ADMINISTERED BY
YOUR COUNTY WELFARE DEPARTMENT:
The County’s Civil Rights Coordinator. Ask
your county office for the name, address and
phone number of their Civil Rights
Coordinator. He/she will independently
investigate your complaint.
2. Civil Rights Bureau
California Department of Social Services
744 P Street, MS 8-16-70
Sacramento, CA 95814
(916) 654-2107
(866) 741-6241 (Toll-Free)
3. FOR THE CALFRESH PROGRAM:
United States Department of Agriculture
Director, Office of Civil Rights,
Room 326-W, Whitten Bldg.
1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410
(202) 720-6382 (voice and TTY)
4. FOR ALL OTHER PROGRAMS:
Health and Human Services
Office of Civil Rights
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310 (voice)
(415) 437-8311 (TDD)
TIME LIMITS TO TAKE ACTION
If you suffer discrimination, you must submit your
complaint within 180 days of the actual
discrimination. If the discrimination also affected
the level of your benefits and services, you must also
ask for a state hearing within 90 days. A
discrimination investigation cannot change your
benefit levels or services…only a state hearing can
do that.
LIMITS ON CERTAIN RIGHTS
Although you have the right to privacy and
confidentiality, there are certain laws that allow
limited exceptions. You can ask the county for
the laws.
QUESTIONS
If you have any questions about the rights listed
here, call the Public Inquiry Unit: toll free
(800) 952-5253. The TDD toll-free telephone
number is (800) 952-8349.
■
Adoption Assistance Program (AAP)
Adult Protective Services
Alcohol and Drug Program
California Food Assistance Program (CFAP)
Medi-Cal
CalWORKs
CalWORKs Child Care
CalWORKs Welfare-to-Work Program/Services
Cash Assistance Program for Immigrants (CAPI)
Child Welfare Services
Denti-Cal
Early & Periodic Screening, Diagnosis, and
Treatment (EPSDT)
CalFresh (Food Stamps)
Foster Care
In-Home Support Services
Kinship Guardian Assistance (Kin-GAP)
Mental Health
PROGRAMS COVERED BY THIS PAMPHLET
■
■
■
■
■
■
Multipurpose Senior Services Program (MSSP)
Personal Care Services Program (PCSP)
Refugee Cash Assistance
Social Services
STATE OF CALIFORNIA
HEALTH AND HUMAN
SERVICES AGENCY
DEPARTMENT OF
SOCIAL SERVICES
This pamphlet is available from your Local
County Welfare Office and at www.cdss.ca.gov in
the following languages:
• Arabic
• Japanese • Russian
• Armenian • Korean • Spanish
• Cambodian • Lao
• Spanish Large Print
• Chinese
• Tagalog
• Mien
• Farsi
• Portugese • Ukranian
• Hmong
• Punjabi • Vietnamese
Also Available in large print, Braille, and Audio CD
PUB 13 (6/11)
YOUR
RIGHTS
UNDER CALIFORNIA
WELFARE PROGRAMS
… for people applying for
or receiving public aid in
California
Tell us if you need help
because of a disability
Ask for a free interpreter
County of Orange
■
■
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■
■
■
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9/10/2013 5:46 PM
p. 40
Bid 017-926202-SL
9/10/2013 5:46 PM
1. Understand what is happening with your
application and aid.
YOU HAVE A RIGHT TO…
All people and organizations providing public
assistance must respect your rights. They can help
you understand and apply for benefits and services.
YOUR RIGHTS
1. Keep records of all your information,
documents, and contacts with the county.
2. Get a receipt when you turn anything in.
3. You can bring someone with you to a meeting
with your worker.
4. Complain. There are 4 ways to do this:
■ Informal: You can ask to speak to a supervisor to
talk about problems with a worker or to go
over the rules and the proposed action on your
aid or services.
■ State Hearing: Ask for a state hearing if there is a
problem with your aid or services. You must
ask for a hearing within 90 days of the county's
action. You may be able to file after 90 days if
you have a good reason, like illness or a
disability.
■ Discrimination complaint: If you feel that the
county has discriminated against you, you can
make a discrimination complaint to the
County’s Civil Rights Coordinator or to the
State Civil Rights Bureau, and to the Federal
Government. You must do this within 180 days
of the discrimination. For more on this, see the
section beginning “Prohibited Discrimination.”
IF YOU ARE HAVING PROBLEMS WITH YOUR AID
OR SERVICES:
2. Get written and oral explanations about your
application and aid.
3. Get a receipt for any documents you turn in.
4. See your case record.
5. See state and county laws and regulations.
6. Ask a judge to review any county decision about
your eligibility, benefits, or services.
7. Not face discrimination in receiving program
benefits or services.
8. File a complaint about discrimination.
9. Get extra help from county staff to make sure
you get your benefits if you have a disability or
impairment that makes it hard to understand
the program rules.
10. Have your information kept confidential.
11. Be treated with courtesy and respect.
You can ask for a state hearing any time you
disagree with a county’s action on your benefits
or services.
You can also ask for a state hearing if the county
is not giving you benefits or services which you
think you should get.
A state hearing is heard by a state Administrative
Law Judge. The county will have someone at
the hearing to explain why they took their
action.
A state hearing is not a court hearing. You do
have the right to have a representative with you.
There are free legal services in every county. They
are listed on the back of your county notices.
You can bring witnesses. You have the right to a
free interpreter. Ask the county how to get one.
• If your problem is with General Assistance
or general relief, you must ask for a county
hearing.
• If your problem is with Social Security
benefits, you must contact the Social
Security Administration.
The county must give you a notice at least 10 days
before any action to change your aid or services takes
place. If you ask for a hearing before the action takes
place, you can get “aid paid pending” your hearing.
This means your aid stays the same until you get a
hearing decision.
You MUST ask for a hearing on any new
notice you get, if you disagree.
CONTINUING YOUR AID OR SERVICES PENDING
A STATE HEARING
■
■
■
■
STATE HEARINGS
■
If the discrimination also affects your benefits or
services, you must also ask for a state hearing if
you wish to challenge the county’s decision on
your benefits or services.
Grievance: You can file a complaint with the
county if they have a grievance procedure. This
does not protect your benefits in the way that
asking for a state hearing does.
■
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■
■
Bid 017-926202-SL
The County does not give you a free interpreter.
A worker tells a certain ethnic group about more
programs and services than people of other
ethnicities.
The County won’t help you get audio tapes of a
program orientation to help you with a
disability that makes it hard for you to read.
A worker learns of your religion or politics and
then treats you differently.
You can’t get to appointments because the
county building does not have an elevator.
EXAMPLES OF DISCRIMINATION
Under State law, welfare agencies may not provide
you aid, benefits or services that is different from aid
provided to others on the basis of
Race, Color, National Origin (including
language), Ethnic Group Identification, Age,
Disability, Religion, Sex, Sexual Orientation,
Political Affiliation, Marital Status, or
Domestic Partnership
Federal laws also prohibit discrimination on several,
although not all, of the bases listed above.
Federal Law also prohibits :
1. Delaying or denying the placement of a child for
adoption or into foster care on the basis of race,
color or national origin of the adoptive or foster
parents, or the child;
2. Denying to any individual the opportunity to
become a foster or adoptive parent on the basis
of race, color or national origin of the individual
or child involved.
PROHIBITED DISCRIMINATION
1. Phone: Ask for a State Hearing by contacting
the CA Department of Social Services at
(800) 743-8525 or (800) 952-5253
2. Fill out the back of your Notice of Action
(NOA) or send a written request to:
CDSS, State Hearing Division
744 P Street M.S. 09-17-37
HOW TO REQUEST A STATE HEARING
County of Orange
p. 41
County of Orange
9/10/2013 5:46 PM
Bid 017-926202-SL
p. 42
County of Orange
9/10/2013 5:46 PM
Bid 017-926202-SL
p. 43
County of Orange
Bid 017-926202-SL
Medi-Cal Services
for Children and
Young Adults:
Early & Periodic Screening,
Diagnosis & Treatment
Mental Health Services
This notice is for children and
young adults (under age 21) who
qualify for Medi-Cal EPSDT services
and their caregivers or guardians
What are EPSDT Services?
•
•
•
EPSDT mental health services are Medi-Cal
services that correct or improve mental health
problems that your doctor or other health care provider finds, even if the health problem will not go away entirely. EPSDT mental health services are provided by county mental health departments.
These problems may include sadness, nervousness, or anger that makes your
life difficult.
You must be under age 21 and have full
scope Medi-Cal to get these services.
How to get EPSDT Services for yourself
(under age 21) or your child
Ask your doctor or clinic about EPSDT services. You
or your child may receive these services if you and
your doctor, or other health care provider, clinic
(such as the Child Health and Disability Prevention
Program), or county mental health department
agree that you or your child need them. You may
also call your local county mental health
department directly. The call is free.
9/10/2013 5:46 PM
Types of EPSDT Services
Some of the services you can get from your county
mental health department are:
•
•
•
•
•
•
•
Individual therapy
Group therapy
Family therapy
Crisis counseling
Case management
Special day programs
Medication for your mental health
Counseling and therapy services may be provided in
your home, in the community, or in another location.
Your county mental health department, and your
doctor or provider will decide if the services you ask
for are medically necessary.
County mental health departments must
approve your EPSDT services.
Every county mental health department has a tollfree phone number that you can call for more information and to ask for EPSDT mental health services.
What are EPSDT
Therapeutic Behavioral Services?
Therapeutic Behavioral Services (TBS) are an EPSDT
specialty mental health service. TBS helps children
and young adults who:
• Have severe emotional problems;
• Live in a mental health placement or are at risk
of placement; or
• Have been hospitalized recently for mental health problems or are at risk for psychiatric
hospitalization.
If you get other mental health services and still feel
very sad, nervous, or angry, you may be able to have
a trained mental health coach help you. This person
could help you when you have problems that might
cause you to get mad, upset, or sad. This person
would come to your home, group home or go with
you on trips and activities in the community.
MC 003 (11/12)
p. 44
County of Orange
Bid 017-926202-SL
Your county mental health department can tell
you how to ask for an assessment to see if you
need mental health services including TBS.
You can ask for a state hearing within 90 days after
exhausting the county mental health department’s
appeal process by doing one of the following:
Who can I talk to about EPSDT
mental health services?
• Call: 1-800-952-5253, or
for TTY 1-800-952-8349;
Your doctor, psychologist, counselor, social worker, or other health or social services provider
can assist you with finding EPSDT mental health services. For children and young adults in a group home or residential facility, talk to the staff about getting additional EPSDT services.
• Write: California Department of Social Services,
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430.
For children in foster care, consult the child’s court-appointed attorney. You can also call your
county mental health department directly.
(Look in your phone book for the toll-free
telephone number, or call the Department of
Health Care Services Mental Health
Ombudsman’s Office).
• Fax: 916-651-5210; or 916-651-2789
Where can I get more information?
For more information please contact the following
offices at the telephone numbers below.
County Mental Health Department
toll–free access number
Look in your local phone book
What if I don’t get the services I want from
my county mental health
department?
Mental Health Ombudsman’s Office
1-800-896-4042
You can file an appeal with your county mental
health department if they deny the EPSDT services
requested by your doctor or provider. You may also
file an appeal if you think you need mental health
services and your provider or county mental health
department does not agree.
Department of Health Care Services website
Call the county mental health department’s toll-free
number to talk to a Problem Resolution (grievance/
appeal) coordinator for information and help. You
may also call the county patients’ rights advocate,
or the Department of Health Care Services, Mental
Health Ombudsman Office.
www.dhcs.ca.gov/services/mh
www.dhcs.ca.gov/services/mh/pages/EPSDT.aspx
9/10/2013 5:46 PM
www.dhcs.ca.gov
For additional information about mental
health and EPSDT, please go to the following
webpages:
p. 45
County of Orange
Bid 017-926202-SL
ON
COUNCIL AGING
ORANGE COUNTY
Do you have Medicare and need help
filling out your Medi-Cal paperwork?
HICAP can help.
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DĞĚŝͲĂůƌĞĚĞƚĞƌŵŝŶĂƚŝŽŶĨŽƌŵƐ͘,/WƐĞƌǀŝĐĞƐĂƌĞƉƌŽǀŝĚĞĚďǇĐŽƵŶƐĞůŽƌƐ
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ŝŶƐƵƌĂŶĐĞƋƵĞƐƚŝŽŶƐ͘
What to expect when you call.
zŽƵƌĐĂůůǁŝůůďĞĂŶƐǁĞƌĞĚďǇĂĐŽƵŶƐĞůŽƌƚŚĂƚǁŝůůƐĐƌĞĞŶǇŽƵƚŽǀĞƌŝĨǇĞůŝŐŝďŝůŝƚǇĨŽƌ
ŽƵƌƐĞƌǀŝĐĞƐ͘/ĨǇŽƵŚĂǀĞDĞĚŝĐĂƌĞ͕ǇŽƵƌĐĂƐĞǁŝůůďĞĂƐƐŝŐŶĞĚƚŽĂƐƉĞĐŝĂůůǇƚƌĂŝŶĞĚ
ĐŽƵŶƐĞůŽƌǁŚŽǁŝůůŚĞůƉǇŽƵďǇƉŚŽŶĞŽƌƐĐŚĞĚƵůĞĂŶŝŶƉĞƌƐŽŶĂƉƉŽŝŶƚŵĞŶƚ͘
Call us.
Council on Aging—Orange County
HICAP - Health Insurance Counseling and Advocacy Program
Phone 800-434-0222 • 714-560-0424
Visit us online at www.coaoc.org
,/WŝƐƉĂƌƚŽĨƚŚĞŶĂƚŝŽŶĂůŶĞƚǁŽƌŬŽĨ^ƚĂƚĞ,ĞĂůƚŚ/ŶƐƵƌĂŶĐĞĂŶĚƐƐŝƐƚĂŶĐĞ
WƌŽŐƌĂŵƐ͕ĂŵĞŵďĞƌŽĨĂůŝĨŽƌŶŝĂ,ĞĂůƚŚĚǀŽĐĂƚĞƐ͕ĂŶĚĨƵŶĚĞĚŝŶƉĂƌƚďǇƚŚĞ
ĂůŝĨŽƌŶŝĂĞƉĂƌƚŵĞŶƚŽĨŐŝŶŐ͕ŵĂŬŝŶŐ,/WKƌĂŶŐĞŽƵŶƚǇ͛ƐŵŽƐƚĚĞƉĞŶĚĂďůĞ
ƐŽƵƌĐĞŽĨŶĞƵƚƌĂů͕ĂĐĐƵƌĂƚĞ͕ĂŶĚƵƉͲƚŽĚĂƚĞŝŶĨŽƌŵĂƚŝŽŶĂďŽƵƚDĞĚŝĐĂƌĞ͘
9/10/2013 5:46 PM
p. 46
County of Orange
Bid 017-926202-SL
Paquete de Re-Determinación Anual de Medi-Cal
Por favor complete y retorne las formas incluidas en la section “Client
Action Forms” en el sobre adjunto.
Su trabajador de Medi-Cal se contactara con Ud. si verificaciones
adicionales son requeridas.
Para
Retornar
Formas de RRR de Medi-Cal
Retorne Estas Formas
Formulario Anual para Volver a Determinar su
Elegibilidad de Medi-Cal
Información Importante para Personas que
Solicitan Medi-Cal
MC 210 RV SP (05/11)
MC 219 (SP) (4/10)
Suplemento de Bienes
MC 210 PS (SP) (05/07)
¿Desea Registrarse para Votar?
NVRA Voter Preference
Form (SP) (01/13)
California Voter Registration Form
No Form #
Noticias de Información
Programa de Tratamiento del Cancer del Seno MC Informing Notice 372
y de la Cerviz (BCCTP)
(SPA) (09/09)
MC 4034 (01/08)
Sus Derechos
PUB 13 (SP) (06/11)
Exámenes Médicos y Dentales
PUB 184 (Spanish 01/04)
Servicios de Medi-Cal para Ninos y Jovenes
Council on Aging – Condado de Orange
(HICAP) Recipientes de Medicare que
Necesitan Ayuda Para llenar los Documentos
de Medi-Cal
MC 003 (SP) (11/12)
No Form #
Medi-Cal RRR Cover Letter - Spanish - 7/1/13
9/10/2013 5:46 PM
p. 47
County of Orange
Bid 017-926202-SL
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Bid 017-926202-SL
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Bid 017-926202-SL
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9/10/2013
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p. 50
4*9=:7(7mNPUHKL
County of Orange
Bid 017-926202-SL
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9/10/2013
5:46 PM
p. 51
4*9=:7(7mNPUHKL
County of Orange
Bid 017-926202-SL
Información Importante Para
Personas Que Solicitan Medi-Cal
Notificación de Privacidad y
Confidencialidad
Las secciones 14011 y 14012 del Código de
Bienestar e Instituciones permite que las oficinas
locales de asistencia pública de los condados
obtengan cierta información de usted, para decidir
si usted, o las personas que usted representa,
pueden obtener beneficios de Medi-Cal. Usted
tiene que proporcionar estos datos para obtener
beneficios de Medi-Cal. La información se
utilizará:
1. Por la oficina local de asistencia pública del
condado, para establecer la elegibilidad inicial y
continua de Medi-Cal.
2. Por el Distribuidor Administrativo
(Administrative Vendor-AV) para tramitar
reclamos y hacer Tarjetas de Identificación
de Beneficios (Benefits Identification CardsBICs).
3. Por el Departamento de Servicios Humanos
y de Salud de los Estados Unidos para llevar
a cabo auditorias y evaluaciones de control de
calidad, y verificar los números que el Estado
asigna a los beneficiarios a quienes paga las
primas de Medicare (Buy-In) y los números de
Seguro Social (Social Security Numbers-SSNs).
4. Para verificar la situación de extranjeros con el
Departamento de Seguridad Nacional (DHS
por sus siglas en inglés) solamente de los
extranjeros que dicen haber sido admitidos
legalmente con residencia permanente, o que
residen permanentemente en los Estados
Unidos bajo el amparo de la ley PRUCOL, o
de extranjeros que recibieron amnistía con una
tarjeta I-688 válida y vigente. La información
que el DHS recibe puede utilizarse solamente
para determinar la elegibilidad de Medi-Cal, y no la
pueden utilizar las autoridades de inmigración,
a menos que usted esté cometiendo fraude.
5. Por proveedores de servicios médicos y
organizaciones para el mantenimiento de la
salud para certificar la elegibilidad.
6. Para identificar la cobertura de seguro médico
y llevar a cabo medidas de recuperación.
Derechos, Responsabilidades y Acuerdos del
Solicitante/Beneficiaro de Medi-Cal
Tengo derecho a:
1. Pedir que un intérprete me ayude a solicitar
Medi-Cal, si tengo dificultades para hablar o
entender el idioma inglés.
2. Solicitar una entrevista en persona con un
representante del condado.
-19/10/2013 5:46 PM
MC 219 (4/10)
3. Que se me trate justamente y con igualdad,
independientemente de mi raza, color, religión,
origen nacional, género, edad o creencias
políticas. 4. Solicitar beneficios como persona incapacitada,
si creo estarlo.
Spanish
p. 52
County of Orange
Tengo derecho a:
5. Recibir información sobre las reglas para
elegibilidad retroactiva de Medi-Cal.
6. Solicitar Medi-Cal, y a que se me informe por
escrito si es que cumplo con los requisitos para
algún programa de Medi-Cal.
7. Repasar los manuales de reglas y regulaciones
del programa de Medi-Cal, si deseo cuestionar
las bases bajo las cuales se aprobó o negó mi
elegibilidad.
8. Que todos los datos que le dé a la oficina
local de asistencia pública del condado se
mantengan en la más estricta confidencialidad,
y a ver esos datos durante las horas hábiles
regulares.
9. Recibir una tarjeta de necesidad inmediata,
cuando esto sea posible y reúna los requisitos,
si tengo una emergencia médica o si estoy
embarazada.
10.Recibir Medi-Cal, según se autorice, mientras
mi situación migratoria satisfactoria se esté
documentando y verificando, si de otra
forma reúno los requisitos. Los extranjeros
que son admitidos legalmente con residencia
permanente, los que residen permanentemente
en los Estados Unidos bajo el amparo de la ley
PRUCOL o los que recibieron amnistía con
una tarjeta I-688 válida y vigente que están en
una situación migratoria satisfactoria.
11.Recibir información sobre el Programa
Salud y Prevención de Discapacidades en
los Niños y Adolescentes (Child Health and
Disability Prevention Program—CHDP) y
sobre el Programa de Nutrición Suplemental
Especial para Mujeres, Bebés y Niños (Special
Supplemental Food Program for Women,
Infants, and Children—WIC), y a pedir ayuda
para recibir esos servicios.
-29/10/2013 5:46 PM
MC 219 (4/10)
Bid 017-926202-SL
12.Recibir información sobre el Programa de
Servicio de Cuidado Personal (Personal Care
Service Program—PCSP), y a pedir ayuda para
recibir esos servicios.
13.Recibir información sobre el Programa de
Evaluación Temprana y Periódica, Diagnosis
y Tratamiento (Early and Periodic Screening,
Diagnosis, and Treatment Program—EPSDT).
14.Pedir y recibir información sobre el Programa
de Planificación Familiar, y a que se me
informe si reúno los requisitos para esos
servicios.
15.Hablar con un trabajador social sobre otros
servicios o recursos públicos o privados que
puedo obtener.
16.Recibir información sobre los Planes de
Atención Médica de Medi-Cal a los que mi
familia y yo podemos subscribirnos, para
seleccionar a un médico y obtener otra
atención médica, y a elegir la opción que yo
prefiera.
17.Reducir mi parte del costo proporcionando
facturas médicas pasadas sin pagar (que yo aún
deba).
18.Reducir mi reserva de bienes para que estén
dentro del límite de bienes de Medi-Cal, a más
tardar el último día del mes durante el cual
quiero Medi-Cal, incluyendo el mes en que
solicite, y a que se me informe cómo puedo
gastar mi exceso de bienes.
19.Dividir los bienes comunes contables (no
exentos), (MIOS Y DE MI CÓNYUGE)
por medio de un acuerdo escrito, en partes
iguales de bienes por separado, si cualquiera
de nosotros ingresa a un establecimiento de
atención a largo plazo (Long Term Care-LTC),
antes del 30 de septiembre de 1989.
Spanish
p. 53
County of Orange
Bid 017-926202-SL
Tengo derecho a:
20.Conservar una cierta cantidad de bienes por
separado y comunes contables, si ingreso a un
establecimiento de LTC el o después del 1º de
enero de 1990. Mi cónyuge y yo tenemos el
derecho a que se nos diga la cantidad.
21.Tener una audiencia estatal, si no estoy
satisfecho con una medida que tomó (o no
tomó) la oficina local de asistencia pública
del condado o el Departamento Estatal de
Servicios de Cuidado de la Salud, excepto
medidas relacionadas con los programas del
Pago de Primas de Seguro Médico (Health
Insurance Premium Payment—HIPP) y
del Plan Médico Colectivo del Empleador
(Employer Group Health Plan—EGHP). Si
yo deseo una audiencia estatal para apelar la
decisión, tengo que solicitarla en un plazo de
90 días a partir de la fecha en que se me envió
por correo la Notificación de Acción (Notice
of Action—NOA). Si no recibo una NOA,
tengo que solicitar una audiencia en un plazo
de 90 días a partir de la fecha en que descubra
la medida (o no medida) con la que no estoy
satisfecho. La fecha de descubrimiento es la
fecha en que yo sepa o debiera haber sabido
sobre la medida. La mejor manera de solicitar
una audiencia es comunicarse a la oficina local
de asistencia pública del condado más cercana.
Tengo la Responsabilidad de Informarle a mi Representante del
Condado en un Plazo de Diez Días (10) Cuando:
1. Los ingresos recibidos por mí, o por cualquier
miembro de mi familia aumenten, disminuyan,
comiencen o paren. Esto incluye ingresos de
la Administración del Seguro Social (Social
Security Administration—SSA), préstamos,
arreglos o cualquier otra fuente.
2. Yo planee cambiar, o ya he cambiado mi lugar
de residencia o dirección postal.
3. Una persona, inclusive un bebé recién nacido,
independientemente de que esté relacionado
conmigo o con mi familia, se mude a o fuera
de mi casa.
4. Uno de los padres ausentes regrese a casa.
5. Yo, o un miembro de mi familia, tenga un
bebé, se embarace o termine un embarazo.
6. Yo, mi cónyuge o cualquier miembro de
mi familia, ingrese o salga de un centro de
convalecencia o de un establecimiento de LTC.
MC 219 (4/10) Spanish
9/10/2013 5:46 PM
7. Yo reciba, transfiera, regale o venda bienes
raíces o personales (incluyendo dinero), o
cuando alguien me regale a mí o a un miembro
de mi familia cosas como un automóvil, una
casa, pagos de seguro, etc.
8. Yo tenga cualesquier gastos que alguien aparte
de mí pague.
9. Yo, o un miembro de mi familia, consiga un
trabajo, cambie de trabajo o ya no tenga un
trabajo.
10.Yo tenga un cambio de gastos relacionados
con mi trabajo o educación. (Por ejemplo:
cuidado de niños, transporte, etc.)
11.Yo, o un miembro de mi familia, nos
incapacitemos física o mentalmente (esto
incluiría a un niño en la familia).
12.Yo, o un miembro de mi familia, solicite
beneficios por incapacidad de la SSA,
Administración para Veteranos o Pensión para
Ferrocarrileros.
-3p. 54
County of Orange
Bid 017-926202-SL
Tengo La Responsabilidad De Informarle A Mi Representante Del
Condado En Un Plazo De Diez Días Cuando:
13.Uno de mis hijos se salga de la escuela o
regrese a la escuela.
15.La cobertura de seguro médico para mí, o para
un miembro de mi familia, cambie.
14.Haya un cambio en la ciudadanía o situación
migratoria de cualquier miembro de mi familia
que solicite o reciba Medi-Cal.
Tengo la Responsabilidad de:
1. C
ompletar y regresar un reporte sobre la
situación, a más tardar en la fecha que se
requiera, cuando se solicite.
2. Dar prueba de que soy residente de California.
3. H
acer una declaración sobre mi ciudadanía o
situación migratoria.
4. P
roporcionar un número de Seguro Social
(SSN) para mí, o para cualquier miembro de
mi familia que tenga un SSN, y que desee
recibir beneficios de Medi-Cal. Si yo soy
ciudadano de los Estados Unidos, nacional
de los Estados Unidos o extranjero con una
situación migratoria satisfactoria, tengo que
solicitar un SSN, y proporcionárselo al condado,
si todavía no tengo uno. Si necesito solicitar un
SSN, puedo obtener ayuda de mi trabajador de
elegibilidad, pero tengo que colaborar con la
Administración del Seguro Social (SSA) para
aclarar cualquier pregunta, o mi Medi-Cal se
negará o interrumpirá. (Los extranjeros que no
tienen una situación migratoria satisfactoria, y
que no tienen un SSN, pueden obtener Medi-Cal
limitado, sin solicitar un SSN, si ellos cumplen
con todas las reglas.)
5. S olicitar cualesquier ingresos que posiblemente
estén a mi disposición, o a la disposición de
cualquier miembro de mi familia.
-49/10/2013 5:46 PM
MC 219 (4/10)
6. Solicitar beneficios de Medicare si estoy ciego,
incapacitado, padezco de una Enfermedad Renal
en su Etapa Final (End Stage Renal Disease)
o tengo 64 años y 9 meses o más y reúno los
requisitos. Soy responsable de informarle a
mis proveedores que tengo cobertura tanto de
Medi-Cal, como de Medicare.
7. S olicitar e inscribirme en cualquier seguro
médico, si éste está a mi disposición, o a la
disposición de mi familia, sin costo alguno.
Tengo la responsabilidad de permanecer inscrito
en el plan médico, cuando Medi-Cal apruebe
el pago de las primas del plan por el Estado de
California.
8. R
eportar al departamento del condado, y
al proveedor de atención médica, cualquier
cobertura o seguro de atención médica
que tenga, o a la que tenga derecho a usar,
incluyendo Medicare. Si yo, intencionalmente, no
doy esta información, es posible que sea culpable
de una ofensa criminal, o que mi proveedor me
cobre.
9. I r a mi plan de atención médica (como por
ejemplo Kaiser, TRICARE o una HMO
de Medicare ) para recibir atención médica.
(Medi-Cal no pagará por ningún servicio
cubierto por el plan.)
10. Dar cualesquier pagos de seguro que reciba al
Estado, si Medi-Cal ya ha pagado mi atención
médica.
Spanish
p. 55
County of Orange
Bid 017-926202-SL
Tengo la Responsabilidad de:
11. Ir a una presentación, si se dan presentaciones,
y hacer una elección por escrito, o contestar,
si se recibe por correo, acerca de cómo deseo
obtener beneficios de Medi-Cal. Si no voy y
hago una elección, o elijo por correo, es posible
que a mí, y los miembros de mi familia que
reúnen los requisitos, se nos inscriba en un Plan
de Atención Médica de Medi-Cal cercano a mi
hogar.
12. Firmar mi BIC, cuando la reciba, y asegurarme
de que se utilice solamente para obtener atención
médica necesaria para mí, o para los miembros
de mi familia que reúnen los requisitos.
13. Llevar mi BIC a mi proveedor médico cuando
me enferme o tenga una cita. En emergencias,
cuando la BIC no está a la mano, tengo que
llevar la BIC al proveedor médico en cuanto me
sea posible.
14. Reportar al departamento del condado cuando
reciba servicios de atención médica a causa de
un accidente o lesión causado por los actos
de otra persona o por no actuar ésta, por los
cuales a Medi-Cal se le ha cobrado o se le podría
cobrar.
15. Colaborar con el Estado o el condado para
establecer la paternidad e identificar cualquier
cobertura médica posible a la que yo, o mi
familia, podríamos tener derecho, a través de
uno de los padres ausentes.
16. Colaborar con el Estado de California, si mi caso
se selecciona para que lo evalúe el equipo de
evaluación del control de calidad. Si me niego a
colaborar, se me interrumpirán mis beneficios de
Medi-Cal.
Entiendo Que:
1. El no dar los datos necesarios, o dar datos
falsos deliberadamente, puede resultar en que
se me nieguen o interrumpan los beneficios de
Medi-Cal. Además, es posible que mi caso sea
investigado por sospechas de fraude.
2. Los datos que doy se verificarán por medio de
computadora con los datos proporcionados por
empleadores, bancos, la SSA, el Departamento
de Impuestos del Estado (Franchise Tax Board),
la agencia de asistencia pública y otras agencias.
Tendré el derecho a dar pruebas para corregir
cualesquier datos que se encuentren que son
erróneos.
3. Los extranjeros que no tienen situación
migratoria satisfactoria, y que no tienen un SSN,
pueden recibir Medi-Cal limitado, sin solicitar
un SSN, si ellos cumplen con todas las reglas.
9/10/2013 5:46 PM
4. Los datos sobre la situación migratoria
proporcionados como parte de la solicitud de
Medi-Cal son confidenciales.
5. En base a mis ingresos, es posible que yo pague,
o se me cobre, parte de mis gastos médicos,
antes de que pueda recibir Medi-Cal.
6. Si no reporto cambios con prontitud, y debido
a esto, recibo beneficios de Medi-Cal por los
cuales no reúno los requisitos, es posible que
tenga que pagar al Departamento de Servicios
de Cuidado de la Salud.
7. Yo o algún miembro de mi familia recibiendo
Medi-Cal no estamos recibiendo asistencia
publica de otro estado.
8. Si recibo Medi-Cal, en base a una incapacidad,
y solicito beneficios por incapacidad de la SSA,
-5p. 56
County of Orange
Bid 017-926202-SL
Entiendo Que:
y la SSA rechaza mi reclamo por incapacidad,
es posible que mi Medi-Cal se interrumpa. Si
apelo mi rechazo de la SSA inmediatamente,
mi Medi-Cal continuará hasta que la SSA
tome una decisión final. Si la SSA aprueba mi
reclamo, entonces mis beneficios de Medi-Cal
continuarán. Si la SSA no aprueba mi reclamo,
entonces mis beneficios de Medi-Cal se
interrumpirán.
9. Como una condición de elegibilidad de
Medi-Cal, todos los derechos a apoyo médico
o a pago por servicios médicos para mí, y para
cualesquier personas que reúnan los requisitos,
por las cuales yo tengo la responsabilidad legal,
se asignan automáticamente al Estado.
10. Si un tribunal ordena el apoyo médico de
uno de los padres ausentes para mis hijos, la
compañía de seguros tiene que permitirme
inscribirme y proporcionar beneficios a mis
hijos, sin el consentimiento del padre ausente.
11. Si no solicito o mantengo cobertura médica sin
costo alguno, o cobertura pagada por el estado,
mis beneficios y/o elegibilidad de Medi-Cal se
negarán o interrumpirán.
12. Cuando solicite Medi-Cal, se me evaluará para
la posible elegibilidad bajo otros programas de
asistencia médica, incluyendo los programas de
HIPP y EGHP.
14. Los proveedores de Medi-Cal no pueden
cobrarme copagos, coseguro o cantidades
deducibles de seguro, a menos que el pago se
utilice para cumplir con mi parte del costo y/o
copago de Medi-Cal.
15. Si se me ingresa a un centro de convalecencia,
y no tengo intenciones de regresar a mi casa,
es posible que el Estado imponga un gravamen
sobre mi propiedad.
16. Después de mi muerte, el Estado tiene derecho
a buscar reembolso de mi patrimonio sucesorio
por todos los beneficios de Medi-Cal que
recibí después de los 55 años, a menos que me
sobrevivan mi cónyuge o mi pareja doméstica
registrada (durante su vida), hijos menores
de edad, hijos ciegos o permanentemente
y totalmente incapacitados, o si esto crearía
dificultades para mis herederos.
17. Después de que muera mi cónyuge o mi pareja
doméstica registrada que me sobrevivió, el
Estado tiene derecho a reclamar de la parte
de su patrimonio sucesorio que recibió de mí,
todos los beneficios de Medi-Cal que recibí
después de los 55 años, hasta la cantidad
máxima de bienes que mi cónyuge o mi pareja
doméstica registrada recibió de mi patrimonio
sucesorio.
13. Si yo solicito a un proveedor médico cualesquier
servicios que no cubre mi plan de seguro
médico que no es Medi-Cal, tengo que dar al
proveedor médico una declaración por escrito
de mi plan médico en donde se indique que no
brinda los servicios cubiertos por Medi-Cal.
-69/10/2013 5:46 PM
MC 219 (4/10)
Spanish
p. 57
County of Orange
Bid 017-926202-SL
Conserve para sus archivos.
Por este medio, declaro que he repasado la información en este formulario con el representante del
condado, y que entiendo completamente mis Derechos y Responsabilidades para que mi elegibilidad de
Medi-Cal se determine, y para mantener esa elegibilidad.
Firma del Solicitante/Representante (opcional) Fecha
County Use Section
I have provided this form to the applicant: (check one) q In Person q By Mail
Eligibility Worker’s Name (print)
Worker number Date
Eligibility Worker’s Signature
9/10/2013 5:46 PM
-7p. 58
County of Orange
State of California—Health and Human Services Agency
Bid 017-926202-SL
Nombre del caso: ____________________________________
Nombre del/de la trabajador(a): _________________________
Teléfono del/de la trabajador(a): _________________________
SUPLEMENTO DE BIENES
PARE: Si usted está solicitando solamente Medi-Cal sin costo alguno, para niños menores de 19 años de
edad o para mujeres embarazadas que solicitan solamente servicios relacionados con el embarazo, usted no
necesita completar este formulario. Es posible que se le llame más tarde, si es necesario.
SIGA: Si usted está solicitando Medi-Cal de cobertura completa, para una familia incluyendo adultos, por
favor, complete este formulario, y asegúrese de incluir todos sus bienes. El/la trabajador(a) del condado
determinará qué bienes son importantes para su solicitud. Si usted tiene alguna pregunta, por favor,
comuníquese con su trabajador(a). Nota: El ser propietario(a) de una casa no impide su elegibilidad para
Medi-Cal.
Marque la casilla debajo de SÍ o NO para cada artículo a nombre de, o que se tiene para el beneficio de,
cualquier miembro de la familia en el hogar. Por favor, siga las indicaciones debajo de cada pregunta.
SÍ
1.
NO
ARTÍCULO
Participaciones de acciones o de fondos comunes de inversión.
Si la respuesta es sí, por favor, proporcione una copia de los certificados de las acciones o
fondos comunes, indicando el número de participaciones.
2.
Cuentas Individuales de Jubilación (IRAs), Keoghs o fondos de pensión relacionados con el
trabajo.
Si la respuesta es sí, por favor, proporcione las declaraciones más recientes de su empleador, institución
financiera o agente financiero, indicando la cantidad del capital y de los intereses que usted esté recibiendo,
o el valor en efectivo (después de las sanciones por retiro temprano).
3.
Pensiones, fideicomisos para entierro, contratos de entierro o seguro de entierro, fideicomisos o
acuerdos, donde se tiene dinero o propiedad, para el beneficio de cualquier miembro de la familia
en el hogar, cuentas congeladas, arreglos financieros, fallos y órdenes de mantenimiento
ordenados por un tribunal, acuerdos prematrimoniales y después del matrimonio, pagarés,
hipotecas, escrituras fiduciarias, etc.
Si la respuesta es sí, por favor, proporcione copias de las pólizas, contratos, fideicomisos, acuerdos de
compra, órdenes del tribunal, documentos de las cuentas, que indiquen las inversiones y las distribuciones.
4.
Cuentas y bienes comerciales.
5.
Casa, condominio, rancho, terreno, casa móvil o derecho a un inmueble durante la vida del
derechohabiente (life estate), que es la casa en la que usted vive, o que es su casa anterior, y en
la que habita su cónyuge, hijo(a) menor de 21 años, hijo(a) incapacitado(a), pariente dependiente
o un(a) hermano(a) que vivió continuamente en la propiedad y que proporcionó cuidado durante
un año, lo cual le permitió a usted permanecer en la casa, y no en un centro de convalecencia.
Si la respuesta es sí, por favor, proporcione declaraciones de impuestos, facturas, recibos,
licencias, declaraciones de ganancias y pérdidas, etc.
Si la respuesta es sí, por favor, indique la dirección de la propiedad aquí: ___________________
No se requiere comprobante.
6.
Si usted es propietario(a) de una casa o de una casa anterior, y usted está ausente por cualquier
motivo (incluyendo el ingreso a un establecimiento de atención a largo plazo), pero tiene la
intención de regresar a casa algún día, por favor, indíquelo abajo. NOTA: La palabra “intención”
significa “deseo” de regresar a casa, aunque sea posible que usted no esté física, ni mentalmente
capacitado(a) para hacerlo.
Sí, yo tengo la intención de regresar a casa algún día.
No, yo no tengo la intención de regresar a casa algún día.
MC 210 PS (SP) (05/07)
9/10/2013 5:46 PM
Página 1 dep.359
County of Orange
Bid 017-926202-SL
Por favor, indique la dirección de la propiedad aquí: ____________________________________
No se requiere comprobante, si usted constestó que tiene la intención de regresar a casa algún día. Si
usted contestó que NO tiene la intención de regresar algún día, por favor, presente una copia de la
valoración fiscal más reciente. Si usted lo decide, puede proporcionar un avalúo, de un(a) evaluador(a)
autorizado(a) de bienes raíces, y se utilizará ese valor, si es menor.
7.
Otros bienes raíces, condominios, edificios, casas móviles, derechos a inmuebles durante la vida
del derechohabiente (life estate), departamentos de tiempo compartido, derechos a petróleo y
minerales.
Si la respuesta es sí, por favor, proporcione copias de los documentos de la hipoteca, las valoraciones
fiscales más recientes, los documentos de registro o de propiedad.
8.
Motocicletas, casas-remolque, barcos u otros vehículos motorizados que usted no utilice como
casa.
Por favor, proporcione una copia de los documentos propietarios o de los registros más recientes, acuerdos
de compra, recibos de venta o presupuestos de su valor, de una fuente autorizada. En el comprobante que
se presente para cada artículo, indique si el artículo se usa: O en el trabajo (como por ejemplo, un taxi); O para recorrer largas distancias a fin de trabajar (como una camioneta utilizada por un contratista que
trabaja fuera de la ciudad);
O para llevar el abastecimiento principal de combustible o agua para su casa;
O para transportar a un(a) pariente incapacitado(a) que vive en la casa, o si es propiedad comercial.
9 .
Joyería (excluyendo anillos de boda, anillos de compromiso o reliquias heredadas) con un valor
de más de $100.00 dólares.
Si la respuesta es sí, por favor, proporcione copias de los recibos de venta, avalúos, presupuestos de valor
o documentos de seguro.
10.
Cualesquier otros bienes raíces o personales, bienes (activos) o recursos valorados en $500.00
dólares o más.
Si la respuesta es sí, envíe copias que comprueben los bienes y su valor.
11.
¿Ha gastado o utilizado alguien cualquiera de los artículos enumerados anteriormente en pago
por, o como garantía para, servicios médicos?
Si la respuesta es sí, por favor, explique enseguida, y adjunte comprobantes.
1 al 10. 12.
Si usted debe dinero en cualquiera de los artículos enumerados anteriormente, o si
cualquiera de los artículos enumerados anteriormente tiene embargos en su contra,
por favor, proporcione copias del embargo, préstamo o documentos de garantía.
Usted, o algún miembro de la familia en el hogar, ¿vendió o regaló dinero o propiedad en:
los últimos 36 meses (ó 60 meses, si la transferencia se hizo a, o desde, un fideicomiso o
acuerdo, a fin de mantener el dinero o la propiedad, para el beneficio de alguien) si usted está
solicitando Medi-Cal; o
O
12 meses si usted está recibiendo Medi-Cal actualmente?
O
Si la respuesta es sí, por favor, explique en la sección de “Información Adicional” al final de este
formulario, y adjunte los comprobantes.
Las siguientes preguntas solamente les son relevantes a las personas que ya están recibiendo Medi-Cal.
13.
¿Hay algún miembro de la familia en el hogar que tenga una cuenta bancaria de cheques o de
ahorros?
Si la respuesta es sí, envíe copias de las declaraciones de estado de cuenta, que muestren los
saldos actuales en las cuentas.
14.
¿Hay alguien que tenga un arreglo financiero o fallo ordenado por el tribunal?
Si la respuesta sí, envíe copias de todas las órdenes judiciales, documentos y acuerdos. Si ya
se le proporcionaron copias a su trabajador(a), usted no tiene que volver a proporcionarlas.
MC 210 PS (SP) (05/07)
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Página 2 dep.360
County of Orange
15.
Bid 017-926202-SL
¿Hay alguien que tenga seguro de vida o seguro de atención a largo plazo?
Si la respuesta es sí, envíe copias de sus pólizas, contratos y acuerdos de compra. Si ya se le
proporcionaron copias a su trabajador(a), usted no tiene que volver a proporcionarlas. Si su
póliza es una póliza certificada por la Asociación de California para la Atención a Largo Plazo,
(California Partnership for Long-Term Care), envíe una copia de su declaración de beneficios
más reciente.
Información adicional:
MC 210 PS (SP) (05/07)
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Página 3 dep.361
County of Orange
Bid 017-926202-SL
Si no está inscrito para votar donde vive ahora, ¿quiere solicitar su inscripción para votar hoy aquí?
(Marque uno)
Ya estoy inscrito.
Estoy inscrito para votar en mi dirección residencial actual.
Sí.
Me quiero inscribir para votar. (Llene la tarjeta adjunta de inscripción para votar.)
No.
No me quiero inscribir para votar.
NOTA: SI NO MARCA UNA CASILLA, SE CONSIDERARÁ QUE HA DECIDIDO NO INSCRIBIRSE PARA VOTAR EN
ESTE MOMENTO. PUEDE LLEVAR EL FORMULARIO DE SOLICITUD DE INSCRIPCION PARA VOTAR
ADJUNTO E INSCRIBIRSE CUANDO LE SEA CONVENIENTE.
___________________________________________________________________
Nombre del solicitante
Fecha
Avisos importantes
1. Si solicita su inscripción para votar, o decide no hacerlo, ello no afectará la cantidad de ayuda provista por esta agencia.
2. Si necesita ayuda para llenar el formulario de solicitud de inscripción para votar, lo ayudaremos a hacerlo. La decisión de
solicitar o aceptar ayuda es sólo suya. Puede llenar el formulario de solicitud en privado.
3. Si cree que alguien interfirió con su derecho a inscribirse para votar, o a no inscribirse, su derecho a privacidad para
decidir si se inscribe o solicita inscribirse para votar, o su derecho a elegir el partido político u otra preferencia política,
puede presentar una queja ante el Secretario de Estado llamando sin cargo al (800) 232-VOTA (8682), o escribiendo a:
Secretary of State, 1500 - 11th Street, Sacramento, CA, 95814. Para obtener más información sobre las elecciones y la
votación, visite el sitio web del Secretario de Estado en www.sos.ca.gov.
01/13 NVRA Voter Preference Form – Spanish
9/10/2013 5:46 PM
p. 62
County of Orange
State of California - Health and Human Services Agency
Bid 017-926202-SL
Programa de Tratamiento del Cáncer de Seno y de la Cerviz (BCCTP)
El Programa BCCTP podría proporcionar Medi-Cal a residentes de California de bajos recursos que
sufren cáncer de seno o de la cerviz.
Si se le ha negado Medi-Cal o ya no es elegible para recibir Medi-Cal en su condado y tiene cáncer
de seno o de la cerviz, informe a su trabajador(a) de elegibilidad (Eligibility Worker - EW) de su
condado. Su EW puede referirla al programa BCCTP.
Un Especialista de Elegibilidad (Eligibility Specialist - ES) del BCCTP la contactará por teléfono
o por escrito para solicitarle más información. La información solicitada nos ayudará a saber si
usted es elegible para el programa. Podría ser elegible para Medi-Cal a través del BCCTP si usted
es mujer y cumple con los requisitos siguientes:
••
••
••
••
••
••
Un proveedor de Every Woman Counts (EWC) o de Family Planning, Access, Care and
Treatment (FamPACT) le ha realizado pruebas y se encontró que necesita tratamiento
para el cáncer de seno o de la cerviz, control médico de seguimiento para el cáncer o
lesiones/enfermedad cervical precancerosa; y
Es residente de California; y
Es menor de 65 años; y
Es ciudadana de Estados Unidos o tiene una condición migratoria satisfactoria; y
No tiene otro seguro médico, incluyendo Medi-Cal de cobertura completa sin pago de
parte del costo, o Medicare ; y
Tiene un ingreso familiar mensual, al momento de las pruebas y diagnóstico, que sea
igual o menor a 200 por ciento del índice de pobreza a nivel federal.
Si un proveedor que no sea EWC o FamPACT le ha realizado pruebas de cáncer de seno o de la
cerviz, puede también ser referida al BCCTP. Su trabajador(a) de BCCTP le ayudará a encontrar
a un proveedor de EWC o FamPACT que pueda confirmar su diagnóstico.
Aún si usted no cumple con todos los requisitos mencionados arriba, podría recibir el BCCTP
a través de un BCCTP financiado por el estado. El BCCTP financiado por el estado puede
ayudarle hasta 18 meses para el cáncer de seno y hasta 24 meses para el cáncer de la cerviz. El
BCCTP financiado por el estado está disponible para hombres y mujeres, independientemente
de su estatus migratorio.
Para más información o preguntas acerca del BCCTP, llame al 1-800-824-0088
MC Info Notice 372 (SPA) (9/09)
9/10/2013 5:46 PM
p. 63
County of Orange
9/10/2013 5:46 PM
Bid 017-926202-SL
p. 64
County of Orange
Bid 017-926202-SL
If you do not understand this information or notification, call your county Medi-Cal worker.
You have the right to interpreter services provided by the county at no cost to you.
Si no entiende esta información o notificación, llame al trabajador de Medi-Cal de su condado.
Tiene derecho a obtener servicios de intérpretes proporcionados por el condado sin costo para Ud.
(Spanish)
‫ ﻟﺪﻳﻚ ﺣﻖ اﳊﺼﻮل ﻋﻠﻰ ﺧﺪﻣﺎت‬.‫ اﳋﺎص ﲟﻘﺎﻃﻌﺘﻚ‬Medi-Cal ‫ إﺗﺼﻞ ﲟﻮﻇﻒ‬، ‫إذا ﻟﻢ ﺗﻔﻬﻢ ﻫﺬه اﳌﻌﻠﻮﻣﺎت أو ﻫﺬا اﻹﺑﻼغ‬
(Arabic) .‫ﺗﺮﺟﻤﺔ ﻣﺠﺎﻧﻴﺔ ﻣﺘﻮﻓﺮة ﻟﻚ ﻣﻦ ﻗِﺒﻞ اﳌﻘﺎﻃﻌﺔ‬
如果您不理解此處的資訊或通知,請電洽您所在縣的Medi-Cal工作人員。您有權免費獲得縣政府
提供的免費口譯服務。 (Chinese)
‫ ﺷﻤﺎ اﻳﻦ ﺣﻖ را دارﻳﺪ ﻛﻪ‬.‫ ﻛﺎﻧﺘﻲ ﺧﻮد ﲤﺎس ﺑﮕﻴﺮﻳﺪ‬Medi-Cal ‫ ﺑﺎ ﻣﺪدﻛﺎر‬،‫اﮔﺮ اﻳﻦ اﻃﻼﻋﺎت و ﻳﺎ اﻃﻼﻋﻴﻪ را درك ﳕﻲ ﻛﻨﻴﺪ‬
(Farsi) .‫ﺑﻪ ﻃﻮر راﻳﮕﺎن از ﺧﺪﻣﺎت ﻣﺘﺮﺟﻢ از ﻃﺮﻳﻖ ﻛﺎﻧﺘﻲ اﺳﺘﻔﺎده ﻛﻨﻴﺪ‬
Yog koj tsis totaub txog cov kev qhia lossis tsab ntawv no, hu rau koj tus neeg tuav ntaub ntawv
Medi-Cal hauv lub county. Koj muaj cai tau txais kev pab txhais lus dawb los ntawm lub county.
(Hmong)
‫҆܄@ێ‬Ǧ@ࣃ‫ݖ‬Էθ@‫ێ‬६०@ր@‫ؾ‬ɜ@Ĉ‫مڐ‬ɜ@ࠥ‫@ࣲڒ‬mMc@ɽʁ@‫مڜݗ‬ö@‫۾‬টॣֲ֫٤N@
Ãۖۜɜ@ࠥ‫ࣲڒ‬Ã@ЛΕ΂@‫܆‬Ěॣɜ@ࣃَ@Էҿ֢θ@ю‫@ڽ‬ŇπÃ@ۘ֨ɩɳN (Korean)
Если вы не понимаете данную информацию или уведомление, позвоните сотруднику
компании Medi-Cal вашего округа. У вас есть право на получение услуг переводчика,
которые предоставляются округом бесплатно. (Russian)
Kung hindi ninyo naiintindihan ang impormasyon o paunawang ito, tawagan ang inyong manggagawa
sa Medi-Cal ng county. Kayo ay may karapatang magkaroon ng mga serbisyo ng tagasalin na ibibigay
ng county na walang bayad sa inyo. (Tagalog)
Neáu quyù vò khoâng hieåu chi tieát hoaëc thoâng baùo naøy, haõy ñieän thoaïi cho nhaân vieân Medi-Cal taïi
quaän quyù vò. Quyù vò coù quyeàn ñöôïc quaän cung caáp dòch vuï thoâng dòch mieãn phí cho quyù vò.
(Vietnamese)
MC 4034 (01/08)
9/10/2013 5:46 PM
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County of Orange
9/10/2013 5:46 PM
Bid 017-926202-SL
p. 66
■
■
■
■
Su silla de ruedas no cabe en los baños o en las salas
donde se llevan a cabo los exámenes o las entrevistas.
Los hombres reciben entrenamiento para empleos
que pagan más y las mujeres reciben entrenamiento
para empleos que pagan menos.
El Condado no quiere proporcionarle entrenamiento
porque dicen que usted es “demasiado viejo”.
No le permiten adoptar a un bebé porque la raza
de usted es diferente a la del bebé.
QUEJAS DE DISCRIMINACIÓN
Si usted cree que ha sido víctima de discriminación, puede
presentar una queja al Condado, al Estado, y al Gobierno
Federal - una queja separada para cada uno. La oficina
específica del Gobierno Federal a la cual debe comunicarse
depende de qué programa se trata su queja.
Puede presentar una queja de discriminación a:
1. PARA TODOS LOS PROGRAMAS QUE SE
ADMINISTRAN POR EL DEPARTAMENTO DE
BIENESTAR PÚBLICO DEL CONDADO:
El coordinador de derechos civiles del Condado.
Pídale a la oficina del Condado el nombre,
dirección, y número de teléfono de su
coordinador de derechos civiles. Él/Ella
investigará su queja independientemente.
2. Civil Rights Bureau
California Department of Social Services
744 P Street, MS 8-16-70
(916) 654-2107
(866) 741-6241 (Gratuito)
3. PARA EL PROGRAMA DE CALFRESH:
United States Department of Agriculture
Director, Office of Civil Rights,
Room 326-W, Whitten Bldg.
1400 Independence Avenue, S.W.,
Washington, D.C. 20250-9410
(202) 720-6382 (voz y TTY)
4. PARA TODOS LOS OTROS PROGRAMAS:
Health and Human Services
Office of Civil Rights
90 7th Street, Suite 4-100
San Francisco, CA 94103
(415) 437-8310 (voz)
(415) 437-8311 (TDD)
LÍMITES DE TIEMPO PARA TOMAR ACCIÓN
■
■
■
■
■
■
■
■
■
Si usted es víctima de discriminación, tiene que
presentar su queja antes de que pasen 180 días a partir
de cuando ocurrió la discriminación. Si la
discriminación también afectó la cantidad de sus
beneficios o servicios, también tiene que pedir una
audiencia con el Estado antes de que pasen 90 días.
Una investigación de discriminación no puede cambiar
la cantidad de sus beneficios o servicios... solamente
una audiencia con el Estado puede hacer eso.
LÍMITES EN CUANTO A CIERTOS DERECHOS
CalFresh (estampillas para comida)
Cuidado de Crianza Temporal (FC)
Programa de Servicios de Apoyo en el Hogar (IHSS)
Programa de Pagos de Asistencia para Parientes que
Son los Tutores Legales de un Menor (Kin-GAP)
Salud Mental
Programa de Servicios Múltiples para Personas
Mayores (MSSP)
Programa de Servicios de Cuidado Personal (PCSP)
Asistencia Monetaria para Refugiados (RCA)
Servicios Sociales
STATE OF CALIFORNIA
(ESTADO DE CALIFORNIA)
SUS
DERECHOS
BAJO LOS PROGRAMAS DE
ASISTENCIA PÚBLICA DE
CALIFORNIA
…… para las personas que
solicitan o reciben asistencia
pública en California
Díganos si necesita ayuda
debido a una incapacidad/
discapacidad.
County of Orange
Este folleto está disponible en los siguientes
idiomas en la oficina de bienestar público de su
condado y en el sitio web: www.cdss.ca.gov
• Japonés • Ruso
• Árabe
• Coreano • Español
• Armenio
• Camboyano • Laosiano • Español (letra grande)
• Mien
• Tagalo
• Chino
• Portugués • Ucraniano
• Farsí
• Penjabi • Vietnamita
• Hmong
También está disponible en Braille, así como una
versión fácil de leer (letra grande), o grabada (audio CD).
DEPARTMENT OF SOCIAL SERVICES
(DEPARTAMENTO DE SERVICIOS SOCIALES)
HEALTH AND HUMAN SERVICES AGENCY
(SECRETARÍA DE SALUD Y SERVICIOS HUMANOS)
Aunque usted tenga derecho a la privacidad y la
confidencialidad, hay ciertas leyes que permiten
excepciones limitadas. Usted puede pedirle al
Condado información sobre estas leyes.
PREGUNTAS
Si tiene alguna pregunta sobre los derechos enumerados en
este folleto, llame a la Oficina de Preguntas y Respuestas al
Público: (800) 952-5253 (Gratuito). El número gratuito de
TDD (aparato de telecomunicaciones para las personas
sordas) es (800) 952-8349.
■
Programa de Asistencia para Adopciones (AAP)
Servicios para la Protección de Adultos (APS)
Programas de Alcohol y Drogas (ADP)
Programa de California para la Asistencia
Alimentaria (CFAP)
Programa de Asistencia Médica de California (Medi-Cal)
Programa de California de Oportunidades de Trabajo
y Responsabilidad hacia los Niños (CalWORKs)
Cuidado de Niños del Programa de CalWORKs
Programa para la Transición de la Asistencia
Pública al Trabajo (WTW) bajo el Programa de
CalWORKs
Programa de Asistencia Monetaria para
Inmigrantes (CAPI)
Servicios para el Bienestar de los Niños (CWS)
Programa de Asistencia Dental de California
(Denti-Cal)
Programa de Evaluación Temprana y Periódica,
Diagnosis, y Tratamiento (EPSDT)
PROGRAMAS CUBIERTOS EN ESTE FOLLETO
■
■
■
■
■
■
■
■
■
■
■
PUB 13 (SP) (6/11)
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Bid 017-926202-SL
1. Entender lo que está pasando con su solicitud y
su asistencia.
2. Obtener explicaciones, por escrito y orales, sobre
su solicitud y sus beneficios.
USTED TIENE DERECHO A …
Todas las personas y organizaciones que proporcionan
asistencia pública tienen que respetar los derechos que
usted tiene. Le pueden ayudar a entender y solicitar
beneficios y servicios.
SUS DERECHOS
9/10/2013 5:46 PM
4. Presente una queja. Hay 4 maneras de hacer esto:
■ Queja informal: Puede pedir hablar con un supervisor
sobre problemas que tiene con un trabajador o para
revisar las reglas y la acción que el Condado propone
tomar en relación a sus servicios o asistencia.
■ Audiencia con el Estado: Pida una audiencia con el
Estado si hay un problema con su asistencia o
sus servicios. Tiene que pedir una audiencia
antes de que pasen 90 días a partir de la
acción del Condado. Es posible que pueda
pedir una audiencia después de los 90 días si tiene
un motivo justificado como una enfermedad o
una incapacidad/discapacidad.
■ Queja de discriminación: Si cree que el Condado ha
discriminado contra usted, puede presentar una
queja de discriminación - al coordinador de
derechos civiles del Condado o a la Oficina de
Derechos Civiles del Estado, y al Gobierno Federal.
Tiene que hacer esto antes de que pasen 180 días a
partir de la discriminación. Para más información
sobre esto, vea la sección que comienza con
“Prohibida la discriminación”. Si la discriminación
también afecta sus beneficios o servicios, también
tiene que pedir una audiencia con el Estado
1. Mantenga un expediente de toda su información,
todos sus documentos, y cualquier contacto con
el Condado que haya tenido.
2. Obtenga un recibo para cada documento que entrega.
SI TIENE PROBLEMAS CON SU ASISTENCIA O
SUS SERVICIOS:
3. Obtener un recibo para cada documento que entrega.
4. Ver el expediente de su caso.
5. Ver las leyes y los ordenamientos del Estado y del
Condado.
6. Pedirle a un juez que revise cualquier decisión del
Condado sobre su elegibilidad, beneficios, o servicios.
7. No ser víctima de discriminación en cuanto a
recibir beneficios o servicios de los programas.
8. Presentar una queja sobre cualquier discriminación.
9. Obtener ayuda adicional del personal del Condado
para asegurarse de que reciba sus beneficos si tiene
una incapacidad/discapacidad o un impedimento
que le hace dificil entender las reglas del programa.
10. Mantener su información de una manera confidencial.
11. Ser tratado con cortesía y respeto.
Puede pedir una audiencia con el Estado si no
está de acuerdo con una acción del Condado en
relación a sus beneficios o servicios.
También puede pedir una audiencia con el
Estado si el Condado no le da los beneficios o
servicios que usted cree que debe recibir.
Un juez de leyes administrativas del Estado está a
cargo de la audiencia con el Estado. Un representante
del Condado estará presente también en la audiencia
para explicar por qué tomó su acción el Condado.
Una audiencia con el Estado no es una audiencia
de la corte. Usted tiene el derecho de llevar un
representante a la audiencia. Hay servicios legales
gratuitos en cada condado los cuales se indican
en la segunda página de las notificaciones del
Condado. Puede llevar testigos. Tiene el derecho
de tener un intérprete gratis. Pregúntele al Condado
cómo hacerlo.
• Si tiene un problema con el Programa de
Asistencia General/Ayuda General, tiene que
pedir una audiencia con el Condado.
• Si tiene un problema con sus beneficios de
Seguro Social, tiene que comunicarse con la
Administración del Seguro Social.
El Condado tiene que darle una notificación por lo
menos 10 días antes de que entre en vigor cualquier
acción que cambie su asistencia o sus servicios. Si pide
una audiencia antes de que entre en vigor la acción,
puede continuar recibiendo asistencia hasta que se
lleve a cabo la audiencia (“aid paid pending”). Esto
significa que su asistencia quedará igual hasta que se
emita una decisión sobre la audiencia.
USTED TIENE QUE pedir una audiencia cada
vez que reciba una notificación sobre cualquier
acción con la cual usted no está de acuerdo.
CONTINUACIÓN DE SU ASISTENCIA O SUS
SERVICIOS MIENTRAS QUE ESPERA UNA
AUDIENCIA CON EL ESTADO
■
■
■
■
AUDIENCIA CON EL ESTADO
■
si desea disputar la decisión del Condado en
relación a sus beneficios o servicios.
Procedimiento para presentar quejas: Puede presentar
una queja al Condado si tienen un procedimiento
para presentar quejas. Esto no protege sus
beneficios de la misma manera que lo hace el
pedir una audiencia con el Estado.
El Condado no le ayuda a obtener cintas de grabación
(audio tapes) de la orientación para un programa para
ayudarle con una incapacidad/discapacidad que le hace
difícil leer.
Un trabajador le trata de una manera diferente al
darse cuenta de su religión o su afiliación política.
No puede llegar a sus citas porque el edificio del
Condado no tiene un ascensor.
■
■
■
Un trabajador les habla a personas de cierto
grupo étnico sobre más programas y servicios
que a personas en otros grupos étnicos.
Bid 017-926202-SL
■
■
EJEMPLOS DE DISCRIMINACIÓN
Bajo las leyes del Estado, las oficinas que proporcionan
asistencia pública no pueden proporcionarle beneficios
o servicios que son diferentes a la asistencia que
proporcionan a otras personas basándose en su:
Raza, Color, Origen Nacional (incluyendo su idioma),
Grupo Étnico, Edad, Incapacidad/Discapacidad,
Religión, Sexo, Orientación Sexual, Afiliación Política,
Estado Civil, o Relación Doméstica
Las leyes federales también prohíben la discriminación basada
en algunas, aunque no todas, las razones antes mencionadas.
Las leyes federales también prohíben:
1. El demorar o negar la colocación de un niño para
su adopción o su ingreso en un hogar de cuidado
de crianza temporal basándose en la raza, color, u
origen nacional de los padres adoptivos/de crianza
temporal o del niño;
2. El negarle a cualquier persona la oportunidad de
hacerse padre/madre adoptivo o de crianza
temporal basándose en la raza, color, u origen
nacional de la persona o del niño involucrado.
PROHIBIDA LA DISCRIMINACIÓN
1. Por teléfono: Pida una audiencia con el Estado,
comunicándose con el Departamento de Servicios
Sociales de California (CDSS) al (800) 743-8525 ó
(800) 952-5253.
2. Complete la segunda página de su notificación de
acción (NOA) o envíe una petición por escrito al
CDSS a la siguiente dirección:
CDSS, State Hearing Division
744 P Street M.S. 09-17-37
CÓMO PEDIR UNA AUDIENCIA CON EL ESTADO
County of Orange
p. 68
¿Qué servicios ofrece CHDP?
Exámenes físicos de rutina:
Examen del crecimiento y
el desarrollo
Todas las vacunas necesarias
Examen de los dientes
Examen de la vista
Examen del oído
Examen de nutrición
Instrucción sobre la salud
Instrucción sobre el tabaco
Pruebas de anemia, plomo en la
sangre, orina, tuberculosis y otras
según sea necesario
Remisión al WIC para niños de hasta
5 años de edad
Información:
Para más información, o ayuda para obtener
una cita y transporte, póngase en contacto con
la oficina local de CHDP. El teléfono está en
la sección de gobierno del directorio
telefónico. Busque bajo Child Health and
Disability Prevention o bajo Health
Department.
O, puede encontrar la dirección de su
oficina CHDP local en:
www.dhcs.ca.gov/services/chdp
Para mas informacion llamar al:
Condado de Orange - Health Care Agency
Programa de CHDP
Numero para solicitar ayuda
1-800-564-8448
Informacion para personas con problemas
auditivos:
1-800-801-7100
Si necesita ayuda para obtener servicios de
salud mental, llame al departamento de salud
mental de su condado. Ellos le pueden dar
información sobre otros servicios para niños y
jóvenes con problemas emocionales serios
que tienen Medi-Cal completo.
Arnold Schwarzenegger
Gobernador del Estado de California
9/10/2013 5:46 PM
PUB 184 (Spanish 1/04)
Spanish
Programa de Salud y
Prevención de Discapacidades
de Niños (CHDP)
Exámenes médicos
y dentales
GRATUITOS
Para bebés, niños y jóvenes
de hasta 20 años
con Medi-Cal completo (Full Scope)
County of Orange
Exámenes dentales con regularidad y
atención adicional, si fuera necesario.
Si necesita más servicios médicos, dentales o
de salud mental, le ayudaremos a encontrarlos.
No tiene que pagar el diagnóstico ni el
tratamiento mientras su hijo reciba Medi-Cal.
Si usted tiene Medi-Cal con costo compartido
puede hacer que CHDP pague el examen o,
usted puede pagar el examen, y hacer que el
costo cuente hacia el pago que le corresponde.
Los servicios de CHDP NO tienen ningún
copago.
Lleve su tarjeta Medi-Cal vigente y el
comprobante de vacunación.
p. 69
Bid 017-926202-SL
9/10/2013 5:46 PM
Entre los 4 y 5 años
Necesitan un examen a estas edades:
Menos de 1 mes
1 a 2 meses
3 a 4 meses
5 a 6 meses
7 a 9 meses
10 a 12 meses
13 a 15 meses
16 a 23 meses
2 años
3 años
¿Cada cuánto?
¿Cada cuánto?
Los exámenes de salud pueden encontrar
problemas que podrían el desempeño escolar
del niño.
¡Los adolescentes también necesitan
exámenes de salud! Es posible que tengan
preguntas sobre su salud. Pueden hablar con
un proveedor de salud.
La ley estatal requiere que niños que entren al
jardín de niños o al primer grado se hagan un
examen de salud y tengan las vacunas al día.
Los bebés y los niños pequeños necesitan
exámenes de salud frecuentes. Necesitan sus
vacunas a tiempo.
Exámenes de salud
Exámenes para entrar a la escuela
Atención y vacunación del bebé sano
programadas
Pregunte a su médico o al departamento
de salud local sobre otros servicios
para adolescentes.
¿Cada cuánto?
13 a 20 años
4 a 12 años
Nacimiento a los 3 años
Adolescentes y adultos jóvenes
Niños en edad escolar
Bebés y niños pequeños
En un examen de salud completo se pueden encontrar problemas médicos, dentales y/o de salud mental antes de que sean
serios. También se dan las vacunas necesarias. Tendrá tiempo para hacer preguntas. Si está requerido, se puede hacer un
examen de salud para cuidado de crianza, deportes o campamentos. Por lo general, los exámenes CHDP se hacen en el
mismo lugar donde recibie sus otros servicios de salud.
¿Por qué hacerles exámenes médicos?
County of Orange
Bid 017-926202-SL
p. 70
County of Orange
Bid 017-926202-SL
Servicios de
Medi-Cal para
Niños y Adultos
Jóvenes:
Detección, Diagnóstico y Tratamiento Oportunos y Periódicos
(Early & Periodic Screening,
Diagnosis & Treatment-EPSDT)
Servicios de Salud Mental
Este aviso es para niños y adultos
jóvenes (menores de 21 años) que
califican para recibir servicios de
EPSDT de Medi-Cal y para sus
cuidadores o tutores
¿Qué son los Servicios de EPSDT?
• Los servicios de salud mental de EPSDT son servicios
de Medi-Cal que corrigen o mejoran problemas de
salud mental que su doctor u otro proveedor de
atención de la salud haya notado, aún en aquellos
casos en que el problema de salud no desaparecerá
por completo. Los departamentos de salud mental
del condado proporcionan los servicios de salud
mental de EPSDT.
• Estos problemas podrían incluir tristeza, nerviosismo
o ira, los cuales pueden hacer su vida difícil.
• Usted debe ser menor de 21 años de edad y
contar con la cobertura completa de Medi-Cal
para recibir estos servicios.
Cómo obtener Servicios de EPSDT para
usted (si es menor de 21 años) o para su hijo
Pregunte a su doctor o clínica acerca de los servicios
de EPSDT. Usted o su hijo podría recibir estos servicios
si usted y su doctor, u otro proveedor de atención de
salud, clínica (tales como el Child Health and Disability
Prevention Program), o un departamento de salud
mental del condado están de acuerdo en que usted
o su hijo los necesita. Usted también podría llamar
directamente a su departamento de salud mental
del condado. La llamada es gratuita.
9/10/2013 5:46 PM
Tipos de Servicios de EPSDT
Algunos de los servicios que usted puede obtener a
través de su departamento de salud mental del
condado son:
•
•
•
•
•
•
•
Terapia individual
Terapia de grupo
Terapia familiar
Asesoría en casos de crisis
Administración de casos
Programas de día especiales
Medicación para su salud mental
Los servicios de asesoría y terapia se podrían
proporcionar en su hogar, en la comunidad o en
otra ubicación.
Su departamento de salud mental del condado y su
doctor o proveedor decidirán si los servicios que usted
solicita son médicamente necesarios.
Los departamentos de salud mental del
condado tienen que aprobar sus servicios
de EPSDT.
Cada departamento de salud mental del condado tiene
un número de teléfono gratuito al cual usted puede
llamar para pedir más información y para solicitar los
servicios de salud mental de EPSDT.
¿Qué son los Therapeutic
Behavioral Services de EPSDT?
Los Therapeutic Behavioral Services (TBS) son un
servicio especializado de salud mental de EPSDT.
Los TBS ayudan a niños y adultos jóvenes que:
• Tienen problemas emocionales severos;
• Viven en una institución de salud mental o están en
riesgo de ser ubicados en una de ellas; o
• Han sido hospitalizados recientemente debido a
problemas de salud mental o están en riesgo de
hospitalización psiquiátrica.
Si usted recibe otros servicios de salud mental y aún
se siente muy triste, nervioso o enojado, usted podría
tener acceso a un asistente de salud mental capacitado
para ayudarlo. Esta persona podría ayudarlo cuando
usted tiene problemas que pueden causarle enojo,
disgusto o tristeza. Esta persona podría visitar su hogar,
el centro donde vive o acompañarlo en sus actividades
en la comunidad.
p. 71
County of Orange
Bid 017-926202-SL
El departamento de salud mental de su condado
puede indicarle cómo pedir una evaluación para ver
si usted necesita servicios de salud mental, incluyendo
los TBS.
Puede pedir una audiencia estatal dentro de los
90 días después de haber agotado el proceso de
apelación ante el departamento de salud mental del
condado mediante una de las acciones siguientes:
¿Con quién puedo hablar acerca de los
servicios de salud mental de EPSDT?
• Llamar al: 1-800-952-5253, o
para TTY 1-800-952-8349;
Su doctor, psicólogo, consejero, trabajador social u
otro proveedor de servicios sociales o de salud puede
ayudarle a encontrar servicios de salud mental de
EPSDT. En el caso de niños y adultos jóvenes que
viven en un centro o instalaciones residenciales,
hable con el personal acerca de los servicios
adicionales de EPSDT.
•
Para niños en crianza temporal, consulte con el
abogado del niño que ha sido nombrado por la
corte. Usted también puede llamar directamente a su
departamento de salud mental del condado. (Busque
en su guía telefónica el número gratuito o llame a
la Oficina de Servicios de Mediación para la Salud
Mental del Department of Health Care Services).
• Enviar Fax: 916-651-5210; o al 916-651-2789
Escribir a: California Department of Social Services,
State Hearings Division
P.O. Box 944243, Mail Station 9-17-37
Sacramento, CA 94244-2430. ¿Dónde puedo obtener información?
Para más información por favor comuníquese con
las siguientes oficinas a través de los números de
teléfono que aparecen a continuación.
Número de acceso gratuito del
Departamento de Salud Mental del Condado
Busque en su guía telefónica local
¿Qué pasa si el departamento de salud
mental de mi condado no me brinda los
servicios que quiero?
Puede presentar una apelación en el departamento
de salud mental de su condado si ellos le niegan
los servicios de EPSDT solicitados por su doctor o
proveedor. Usted también podría presentar una
apelación si usted piensa que necesita servicios de
salud mental y su proveedor o el departamento de
salud mental del condado no está de acuerdo.
Llame al número gratuito del departamento de salud
mental del condado para hablar con un coordinador
de Resolución de Problemas (queja/apelación)
para pedir información y ayuda. Usted también
podría llamar al defensor de los derechos de los
pacientes en el condado o a la Oficina de Servicios de
Mediación para la Salud Mental del Department of
Health Care Services.
9/10/2013 5:46 PM
La Oficina de Servicios de
Mediación para la Salud Mental del
1-800-896-4042
Sitio web del
www.dhcs.ca.gov
Para encontrar información adicional acerca
de la salud mental y los EPSDT, visite las páginas
web siguientes:
www.dhcs.ca.gov/services/mh
www.dhcs.ca.gov/services/mh/pages/EPSDT.aspx
p. 72
County of Orange
Bid 017-926202-SL
ON
COUNCIL AGING
ORANGE COUNTY
¿Tiene Medicare y necesita ayuda
con la aplicación de Medi-Cal?
HICAP le puede ayudar.
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Lo que puede esperarse cuando nos llame.
hŶĐŽŶƐĞũĞƌŽĐŽŶƚĞƐƚĂƌĄƐƵůůĂŵĂĚĂǇƌĞǀŝƐĂƌĄƐŝĐĂůŝĨŝĐĂƉĂƌĂŶƵĞƐƚƌŽƐƐĞƌǀŝĐŝŽƐ͘^ŝ
ƚŝĞŶĞDĞĚŝĐĂƌĞ͕ƐƵĐĂƐŽƐĞƌĄĂƐŝŐŶĂĚŽĂƵŶĐŽŶƐĞũĞƌŽƋƵĞůĞĂǇƵĚĂƌĄƉŽƌƚĞůĠĨŽŶŽŽ
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Llámenos.
Council on Aging—Orange County
HICAP - Programa de Consejeria y Abogacia de Seguros Médicos
Teléfono 800-434-0222 • 714-560-0424
Visítenos en la página de internet www.coaoc.org
ůƉƌŽŐƌĂŵĂĚĞ,/WĞƐƉĂƌƚĞĚĞůĂƌĞĚŶĂĐŝŽŶĂůĚĞWƌŽŐƌĂŵĂƐĚĞƐŝƐƚĞŶĐŝĂǇ
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,/WĞůŵĄƐĨŝĂďůĞĚĞŶƚƌŽĚĞŶƵĞƐƚƌĂĐŽŵƵŶŝĚĂĚĐŽŶŝŶĨŽƌŵĂĐŝŽŶƐŽďƌĞDĞĚŝĐĂƌĞ
ƋƵĞĞƐŶĞƵƚƌĂů͕ĞǆĂĐƚĂǇůĂŵĄƐĂĐƚƵĂůŝǌĂĚĂ͘
9/10/2013 5:46 PM
p. 73
County of Orange
Bid 017-926202-SL
NOW, THEREFORE, the Parties mutually agree as follows:
General Terms and Conditions:
A.
B.
C.
D.
E.
F.
G.
H.
Governing Law and Venue: This Contract has been negotiated and executed in the state of California
and shall be governed by and construed under the laws of the state of California. In the event of any legal
action to enforce or interpret this Contract, the sole and exclusive venue shall be a court of competent
jurisdiction located in Orange County, California, and the Parties hereto agree to and do hereby submit to
the jurisdiction of such court, notwithstanding Code of Civil Procedure Section 394. Furthermore, the
Parties specifically agree to waive any and all rights to request that an action be transferred for trial to
another County.
Entire Contract: This Contract, including Attachments A, B, and Exhibit 1 (Blank Child Support
Enforcement Certification Requirements Form) which have been incorporated, when accepted by the
Contractor either in writing or by the shipment of any article or other commencement of performance
hereunder, contains the entire Contract between the Parties with respect to the matters herein and there are
no restrictions, promises, warranties or undertakings other than those set forth herein or referred to herein.
No exceptions, alternatives, substitutes or revisions are valid or binding on County unless authorized by
County in writing. Electronic acceptance of any additional terms, conditions or supplemental Contracts
by any County employee or agent, including but not limited to installers of equipment, shall not be valid
or binding on County unless accepted in writing by County’s Purchasing Agent or his designee,
hereinafter “Purchasing Agent”.
Amendments: No alteration or variation of the terms of this Contract shall be valid unless made in
writing and signed by the Parties; no oral understanding or agreement not incorporated herein shall be
binding on either of the Parties; and no exceptions, alternatives, substitutes or revisions are valid or
binding on County unless authorized by County in writing.
Taxes: Unless otherwise provided herein or by law, price quoted does not include California state sales or
use tax.
Delivery: Time of delivery of goods or services is of the essence in this Contract. County reserves the
right to refuse any goods or services and to cancel all or any part of the goods not conforming to
applicable specifications, drawings, samples or description, or services that do not conform to the
prescribed statement of work. Acceptance of any part of the order for goods shall not bind County to
accept future shipments, nor deprive it of the right to return goods already accepted, at Contractor’s
expense. Over shipments and under shipments of goods shall be only as agreed to in writing by County.
Delivery shall not be deemed to be complete until all goods, or services, have actually been received and
accepted in writing by County.
Acceptance/Payment: Unless otherwise agreed to in writing by County, 1) acceptance shall not be
deemed complete unless in writing and until all the goods/services have actually been received, inspected,
and tested to the satisfaction of County, and 2) payment shall be made according to the requirements
outlined in Attachment B, Compensation and Pricing Provisions.
Warranty: Contractor expressly warrants that the goods/services covered by this Contract are 1) free of
liens or encumbrances, 2) merchantable and good for the ordinary purposes for which they are used, and
3) fit for the particular purpose for which they are intended. Acceptance of this order shall constitute an
agreement upon Contractor’s part to indemnify, defend and hold County and its indemnities as identified
in paragraph “GG” harmless from liability, loss, damage and expense, including reasonable counsel fees,
incurred or sustained by County by reason of the failure of the goods/services to conform to such
warranties, faulty work performance, negligent or unlawful acts, and non-compliance with any applicable
state or federal codes, ordinances, orders, or statutes, including the Occupational Safety and Health Act
(OSHA) and the California Industrial Safety Act. Such remedies shall be in addition to any other
remedies provided by law.
Patent/Copyright Materials/Proprietary Infringement: Unless otherwise expressly provided in this
Contract, Contractor shall be solely responsible for clearing the right to use any patented or copyrighted
materials in the performance of this Contract. Contractor warrants that any Software as modified through
services provided hereunder will not infringe upon or violate any patent, proprietary right, or trade secret
right of any third party. Contractor agrees that, in accordance with the more specific requirement
contained in paragraph “GG” below, it shall indemnify, defend and hold County and County Indemnitees
GeneralTermsandConditions
9/10/2013 5:46 PM
Page1
p. 74
County of Orange
I.
Bid 017-926202-SL
harmless from any and all such claims and be responsible for payment of all costs, damages, penalties and
expenses related to or arising from such claim(s), including, but not limited to, attorney’s fees, costs and
expenses.
Assignment or Sub-contracting: The terms, covenants, and conditions contained herein shall apply to
and bind the heirs, successors, executors, administrators and assigns of the Parties. Furthermore, neither
the performance of this Contract nor any portion thereof may be assigned or sub-contracted by Contractor
without the express written consent of County. Any attempt by Contractor to assign or sub-contract the
performance or any portion thereof of this Contract without the express written consent of County shall be
invalid and shall constitute a breach of this Contract.
In the event that the Contractor is authorized by the County to subcontract, this Contract shall prevail and
the terms of the subcontract shall incorporate by reference and not conflict with the terms of this Contract.
In the manner in which the County expects to receive services, the County shall look to the Contractor for
performance and not deal directly with any subcontractor. All matters related to this Contract shall be
handled by the Contractor with the County; the County will have no direct contact with the subcontractor
in matters related to the performance of this Contract. All work must meet the approval of the County of
Orange.
J.
K.
L.
M.
N.
O.
P.
Non-Discrimination: In the performance of this Contract, Contractor agrees that it will comply with the
requirements of Section 1735 of the California Labor Code and not engage nor permit any subcontractors
to engage in discrimination in employment of persons because of the race, religious creed, color, national
origin, ancestry, physical disability, mental disability, medical condition, marital status, or sex of such
persons. Contractor acknowledges that a violation of this provision shall subject Contractor to all the
penalties imposed for a violation of anti-discrimination law or regulation, including but not limited to,
Section 1720 et seq. of the California Labor Code.
Termination: In addition to any other remedies or rights it may have by law, County has the right to
terminate this Contract without penalty immediately with cause or after 30 days’ written notice without
cause, unless otherwise specified.
Cause shall be defined as any breach of Contract, any
misrepresentation or fraud on the part of the Contractor. Exercise by County of its right to terminate the
Contract shall relieve County of all further obligation. If the Contract is terminated for any reason,
County shall be entitled to an immediate refund of 1/12th of Contract amount multiplied by the number of
months remaining in the paid annual maintenance/support period.
Consent to Breach Not Waiver: No term or provision of this Contract shall be deemed waived and no
breach excused, unless such waiver or consent shall be in writing and signed by the Party claimed to have
waived or consented. Any consent by any Party to, or waiver of, a breach by the other, whether express
or implied, shall not constitute consent to, waiver of, or excuse for any other different or subsequent
breach.
Remedies Not Exclusive: The remedies for breach set forth in this Contract are cumulative as to one
another and as to any other provided by law, rather than exclusive; and the expression of certain remedies
in this Contract does not preclude resort by either Party to any other remedies provided by law.
Independent Contractor: Contractor shall be considered an independent Contractor and neither
Contractor, its employees nor anyone working under Contractor shall be considered an agent or an
employee of County. Neither Contractor, its employees nor anyone working under Contractor, shall
qualify for workers’ compensation or other fringe benefits of any kind through County.
Performance: Contractor shall perform all work under this Contract, taking necessary steps and
precautions to perform the work to County’s satisfaction. Contractor shall be responsible for the
professional quality, technical assurance, timely completion, and coordination of all documentation and
other goods/services furnished by the Contractor under this Contract. Contractor shall perform all work
diligently, carefully, and in a good and workman-like manner; shall furnish all labor, supervision,
machinery, equipment, materials, and supplies necessary therefore; shall at its sole expense obtain and
maintain all permits and licenses required by public authorities, including those of County required in its
governmental capacity, in connection with performance of the work; and, if permitted to subcontract,
shall be fully responsible for all work performed by subcontractors.
Bills and Liens: Contractor shall pay promptly all indebtedness for labor, materials, and equipment used
in performance of the work. Contractor shall not permit any lien or charge to attach to the work or the
premises, but if any does so attach, Contractor shall promptly procure its release and, in accordance with
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County of Orange
Q.
R.
S.
T.
U.
V.
W.
X.
Y.
Z.
AA.
BB.
CC.
DD.
the requirements of paragraph “GG” below, indemnify, defend, and hold County harmless and be
responsible for payment of all costs, damages, penalties and expenses related to or arising from or related
thereto.
Changes: Contractor shall make no changes in the work or perform any additional work without the
County’s specific written approval.
Change of Ownership: Contractor agrees that if there is a change or transfer in ownership of
Contractor’s business prior to completion of this Contract, the new owners shall be required under terms
of sale or other transfer to assume Contractor’s duties and obligations contained in this Contract and
complete them to the satisfaction of County.
Force Majeure: Contractor shall not be assessed with liquidated damages or unsatisfactory performance
penalties during any delay beyond the time named for the performance of this Contract caused by any act
of God, war, civil disorder, employment strike or other cause beyond its reasonable control, provided
Contractor gives written notice of the cause of the delay to County within 36 hours of the start of the
delay and Contractor avails himself of any available remedies.
Confidentiality: Contractor agrees to maintain the confidentiality of all County and County-related
records and information pursuant to all statutory laws relating to privacy and confidentiality that currently
exist or exist at any time during the term of this Contract. All such records and information shall be
considered confidential and kept confidential by Contractor and Contractor’s staff, agents and employees.
Compliance with Laws: Contractor represents and warrants that services to be provided under this
Contract shall fully comply, at Contractor’s expense, with all standards, laws, statutes, restrictions,
ordinances, requirements, and regulations (collectively “laws”), including, but not limited to those issued
by County in its governmental capacity and all other laws applicable to the services at the time services
are provided to and accepted by County. Contractor acknowledges that County is relying on Contractor to
ensure such compliance, and pursuant to the requirements of paragraph “GG” below, Contractor agrees
that it shall defend, indemnify and hold County and County Indemnitees harmless from all liability,
damages, costs, and expenses arising from or related to a violation of such laws.
Freight (F.O.B. Destination): Contractor assumes full responsibility for all transportation, transportation
scheduling, packing, handling, insurance, and other services associated with delivery of all products
deemed necessary under this Contract.
Pricing: The Contract price shall include full compensation for providing all required goods in
accordance with required specifications, or services as specified herein or when applicable, in the Scope
of Work attached to this Contract, and no additional compensation will be allowed therefore, unless
otherwise provided for in this Contract.
Waiver of Jury Trial: Each Party acknowledges that it is aware of and has had the opportunity to seek
advise of counsel of its choice with respect to its rights to trial by jury, and each Party, for itself and its
successors, creditors, and assigns, does hereby expressly and knowingly waive and release all such rights
to trial by jury in any action, proceeding or counterclaim brought by any Party hereto against the other
(and/or against its officers, directors, employees, agents, or subsidiary or affiliated entities) on or with
regard to any matters whatsoever arising out of or in any way connected with this Contract and /or any
other claim of injury or damage.
Terms and Conditions: Contractor acknowledges that it has read and agrees to all terms and conditions
included in this Contract.
Headings: The various headings and numbers herein, the grouping of provisions of this Contract into
separate clauses and paragraphs, and the organization hereof are for the purpose of convenience only and
shall not limit or otherwise affect the meaning hereof.
Severability: If any term, covenant, condition, or provision of this Contract is held by a court of
competent jurisdiction to be invalid, void or unenforceable, the remainder of the provisions hereof shall
remain in full force and effect and shall in no way be affected, impaired or invalidated thereby.
Calendar Days: Any reference to the word "day" or "days" herein shall mean calendar day or calendar
days, respectively, unless otherwise expressly provided.
Attorney Fees: In any action or proceeding to enforce or interpret any provisions of this Contract, or
where any provisions hereof is validly asserted as a defense, each Party shall bear its own attorney’s fees,
costs and expenses.
Interpretation: This Contract has been negotiated at arm’s length and between persons sophisticated and
knowledgeable in the matters dealt with in this Contract. In addition, each Party has been represented by
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County of Orange
EE.
FF.
GG.
experienced and knowledgeable independent legal counsel of their own choosing or has knowingly
declined to seek such counsel despite being encouraged and given the opportunity to do so. Each Party
further acknowledges that they have not been influenced to any extent whatsoever in executing this
Contract by any other Party hereto or by any person representing them, or both. Accordingly, any rule or
law (including California Civil Code Section 1654) or legal decision that would require interpretation of
any ambiguities in this Contract against the Party that has drafted it is not applicable and is waived. The
provisions of this Contract shall be interpreted in a reasonable manner to affect the purpose of the Parties
and this Contract.
Authority: The Parties to this Contract represent and warrant that this Contract has been duly authorized
and executed and constitutes the legally binding obligation of their respective organization or entity,
enforceable in accordance with its terms.
Employee Eligibility Verification: The Contractor warrants that it fully complies with all Federal and
State statutes and regulations regarding the employment of aliens and others and that all its employees
performing work under this Contract meet the citizenship or alien status requirement set forth in Federal
statues and regulations. The Contractor shall obtain, from all employees performing work hereunder, all
verification and other documentation of employment eligibility status required by Federal or State statutes
and regulations including, but not limited to, the Immigration Reform and Control Act of 1986, 8 U.S.C.
§1324 et seq., as they currently exist and as they may be hereafter amended. The Contractor shall retain
all such documentation for all covered employees for the period prescribed by the law. The Contractor
shall indemnify, defend with counsel approved in writing by County, and hold harmless, the County, its
agents, officers, and employees from employer sanctions and any other liability which may be assessed
against the Contractor or the County or both in connection with any alleged violation of any Federal or
State statutes or regulations pertaining to the eligibility for employment of any persons performing work
under this Contract.
Indemnification Provisions: Contractor agrees to indemnify, defend with counsel approved in writing
by County, and hold County, its elected and appointed officials, officers, employees, agents and those
special districts and agencies which County’s Board of Supervisors acts as the governing Board (“County
Indemnitees”), harmless from any claims, demands or liability of any kind or nature, including but not
limited to personal injury or property damage, arising from or related to the services, products or other
performance provided by Contractor pursuant to this Contract. If judgment is entered against Contractor
and County by a court of competent jurisdiction because of the concurrent active negligence of County or
County Indemnitees, Contractor and County agree that liability will be apportioned as determined by the
court. Neither Party shall request a jury apportionment.
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County of Orange
Bid 017-926202-SL
Question and Answers for Bid #017-926202-SL - Social Services Agency Medi-Cal
Annual Redetermination Packets
OVERALL BID QUESTIONS
There are no questions associated with this bid. If you would like to submit a question, please click on the "Create New Question" button below.
Question Deadline: Sep 12, 2013 1:00:00 PM PDT
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Solicitation 017-926202-SL Social Services Agency

Transcripción

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