We offer competitive Medi-Cal friendly annuities. 

Free Medi-Cal Evaluationcalifornia_medi-cal_specialists.gif, California, SSI, Medi-Cal, free evaluation

Find out if you qualify for Medi-Cal.
You do not have to let Long Term Care consume your assets.
There is something you can do to control the situation.
Fill out the form below to learn how you can protect your home, assets and life's savings.california_medi-cal_specialists.gif, California, SSI, Medi-Cal, free evaluation

This information is not sold or made available to any firm or party other than Medi-Cal Specialists.
If you do not want to transmit this form via e-mail, you can fill this form out, print it and Mail it to: Medi-Cal Specialists, at the address at the bottom of this page.    Click here to read our privacy policy.

Personal Data Sheet
In order to show you how you (or your parent(s) can meet Medi-Cal's 2 tests, we need all of the following information. If you are inquiring for your parent(s), complete the form using their information. At the end of the form you can tell us whom to contact when we finish analyzing your situation.

First Name     Last Name 

E-mail         (required for response)

Home Telephone (please include area code)

Work Telephone  (please include area code)

Address 

City State Zip

Date of Birth  Place of Birth (city/state)

Current Health Concerns

Please provide the following personal data for applicant's spouse:

First Name     Last Name

Date of Birth  Place of Birth (city/state)

Current Health Concerns

Financial Analysis
Please provide only rough figures. We don't need exact figures at this time.
We Keep this Information confidential!

Cash & Savings:
This includes: Checking Account, Certificate of Deposit, Treasury Bills, Credit Union, Money Market and Savings Account(s).
Please select the numbers which closely resemble your situation.

Market Securities:
This includes: Stocks, Bonds, Mutual Funds, Annuities, Gold & Silver, Single Premium Whole Life Insurance.
Please select the numbers which closely resemble your situation.

Real Estate (Other Than Home)::

Property #1:

Type City

Market Value — Mortgage = Equity
______________________________________________________________________

Property #2:

Type City

Market Value — Mortgage = Equity
______________________________________________________________________

Total Real Estate Equity  


Other Assets: Approximate Value—Just a Ball Park Figure.
This includes such assets as: Business Interests, Limited Partnerships, First & Second Trust Deeds, (where you are the bank), Money owed to you.

   Total Other Assets


Family Residence:

Type City

Market Value — Mortgage = Equity

            Total Home Equity  

Personal Property:
Includes furniture, fixtures, antiques, paintings, clothing, furs, jewelry, automobiles, recreation vehicles, hobbies, coins, stamps, tools, etc.

            Personal Property  

Retirement Plans: Approximate Value

IRA, 401K or Other

Pension Plan         

Life Insurance:

Husband: Face Value Cash Value

       Wife: Face Value Cash Value

Do you currently have long term care insurance? Yes   No

Do you currently have a living trust? Yes   No

What is your monthly income?

What is the source of this income? (eg. Social Security, Wages, etc)

To whom should we send this evaluation?

Name    

E-mail  (* Information required for us to send you a response)

Comments:

Privacy Policy:
Medi-Cal Specialists do not provide, sell, make available, or distribute any information (including email addresses) about visitors to our web site to anyone, for any reason. Furthermore, "leads" generated by our clients will not be sold, or made available to anyone, for any reason.

Thank you for visiting our Web Site

Note: Medi-cal Specialists do not dispense legal advice.

This website is for informational purposes only and not to be construed as giving legal advice.
We make every effort to provide fast, up to date information on our web site, but due to the constant and frequent changes in the Medi-Cal LTC arena, please be aware that some information provided here may not have caught up with recent changes. Please contact us if you have any questions about any information on our site. Medi Cal, California Medi-Cal Specialists, California, SSI, Medi-Cal, Medicaid, Medi-Cal Benefits, Entitlements, Assisted Living, Long Term Care, Eligibility, Qualifications

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 © Medi-Cal Specialists, 1998-2007               E-mail
937 J. St., Crescent City, CA. 95531     Tel: 1 707 464 6019    FAX: 1707 464 2357

Member LUTCF  California Insurance License # 0799922

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