California Code, Health and Safety Code - HSC § 1599.78

(1) The notice shall state the reason for the transfer or discharge.

(2) The notice shall include the following statement:

“At the time of admission, this facility is an enrolled provider with the following: _____ Medi-Cal______ Medicare.

If we participate in Medi-Cal, you will not be discharged from the facility or transferred within the facility, solely as a result of changing your manner of purchasing the services from private payment or Medicare to Medi-Cal, except for a potential transfer within the facility from a private room to a semiprivate room.

If we participate in Medi-Cal, you may be eligible for the Long-Term Care Medi-Cal program to help pay for your stay in the facility. For more information, refer to the attached notice DHCS 7077, Notice Regarding Standards for Medi-Cal Eligibility, from the State Department of Health Care Services. Medi-Cal, Medicare, or a private payor may require that the resident pay a copayment, coinsurance, or a deductible, all of which the facility considers to be the resident's share of cost.”