Form MC 604 IPS: Fill Out Online in 2026

Form MC 604 IPS, Important Information for Persons Who Are Institutionalized and Their Spouses, is a California Medi-Cal form. It applies when one spouse lives in an institution, such as a nursing home, while the other spouse lives in the community. The California Department of Health Care Services uses the information to help decide Medi-Cal eligibility.

The form explains what income and property details you must provide with an application or renewal packet. It also lists the proof you may need, such as records of income, bank accounts, or other assets. These details help protect the community spouse from financial hardship while Medi-Cal reviews coverage for the institutionalized spouse. Missing documents or incomplete answers may delay the decision or put coverage at risk.

You may receive Form MC 604 IPS when you apply for or renew Medi-Cal and either you or your spouse lives in a medical institution. It collects income, property, and expense details for both spouses and for children under 21 who live at home or are away for school, work, or hospital care.

The county uses these details to decide Medi-Cal eligibility under spousal impoverishment rules. These rules help protect the spouse living in the community from losing too much income or property. The form also records spouses living apart, step-parent households, and children cared for by another relative in the home. It tells you what proof to include with your application or renewal packet.

Form MC 604 IPS is issued by the California Department of Health Care Services (DHCS), part of the California Health and Human Services Agency. DHCS lists it with its Medi-Cal eligibility forms.

PDFLeader has a blank copy pre-loaded in our browser-based editor, so you do not need to find a template elsewhere. You can fill out the form and download the completed PDF for future use. PDFLeader does not file or submit Form MC 604 IPS. Follow the delivery instructions from DHCS or your county office.

Return the completed Form MC 604 IPS to the county Medi-Cal eligibility office handling your case. Address it to the assigned eligibility worker named on your notice.

The delivery method depends on your county’s rules. Many counties let you upload the form through their benefits portal. You may also be able to mail or fax it, or drop it off in person at the local county human or social services office. Follow the instructions on your notice. If no method is listed, contact your assigned worker or county office before sending the form.

County Medi-Cal eligibility workers and the applicant or beneficiary household complete Form MC 604 IPS together. The worker sends the form and identifies which income or property details are needed. The institutionalized spouse, head of household, or authorized representative provides information for everyone in the case. The community spouse also supplies requested details. Household members may need to provide proof, such as pay stubs or account statements.

After the household returns the form, the county eligibility worker uses it. The worker reviews the answers against supporting records and updates the Medi-Cal case file. This information supports decisions on eligibility, share of cost, and MAGI or non-MAGI status during an initial application, annual renewal, or redetermination.

No signature is needed for Form MC 604 IPS. You can fill out the form in PDFLeader and download the completed copy for future use. PDFLeader does not submit or file it for you. Check the latest instructions from the California Department of Health Care Services before completing the form, since requirements may change.

Have the case name, case number, worker's name, worker's phone number, date sent, and return date ready. You may also need the name of anyone living apart from a spouse, each step-parent and their children, and any caretaker relative and the children in their care. Gather income and expense details for you, your spouse, and children under 21 who live at home or are temporarily absent.

For Item 21, if you have a Certified California Partnership for Long-Term Care Insurance policy, attach a copy. If you received benefits, also attach the most recent benefit statement. For Item 22, report any money or property sold or given away in the past 12 months, if the question applies, and attach an explanation and proof. Read the last page and sign the original form in ink.

Form MC 604 IPS has no fixed statutory deadline. Your county eligibility worker sets the due date by entering it in the “Return this Form By” field.

Check your copy for that date and return the completed form by the stated deadline. Respond promptly to help prevent delays in processing your eligibility information. If the field is blank or you cannot meet the date, contact your eligibility worker using the phone number listed on the form.

When your county worker has not specifically requested it, you do not need to complete Form MC 604 IPS on your own. It is also not required if your Medi-Cal case uses only MAGI rules and does not need a non-MAGI review.

You may not need a new Form MC 604 IPS if the county already has the needed income or property verification on file. Follow the county worker’s request and contact the county if you are unsure whether current records are enough.