California Code, Welfare and Institutions Code - WIC § 14006.7

(a) At the time of application for Medi-Cal benefits, the department shall provide to any applicant who is aged, blind, or disabled, other than an individual applying for, or receiving, aid under Chapter 2 (commencing with Section 11200), Article 5 (commencing with Section 12200) of Chapter 3, or Article 7 (commencing with Section 12300) of Chapter 3, and to the applicant's spouse, legal representative, or agent, if any, a clear and simple statement, in writing, in a form and language specified by the department, that explains the circumstances under which an interest in a home may be transferred for less than fair market value without affecting Medi-Cal eligibility.

(b) The statement required by subdivision (a) shall be in the following form:

A transfer of property interest for less than fair market value in a Medi-Cal beneficiary's home will not cause ineligibility for Medi-Cal benefits if at the time of the transfer, the home would have been considered an exempt resource.

This is only a brief description of the Medi-Cal eligibility rules. For more detailed information, you should call your county welfare department. You will probably want to consult with an attorney, your local legal services program for seniors, or the local branch of the long-term care ombudsman program.

I have read the above notice and have received a copy.

Dated: _____ Signature: _______”

(c) The statement required by subdivision (a) shall be printed in at least 12-point type, shall be clearly separate from any other document or writing, and may be signed by the applicant, the applicant's spouse, legal representative, or agent, if any. Failure to sign this form shall not result in ineligibility for medical assistance.

(d) The department may revise this statement as necessary to maintain its consistency with state and federal law.

(e) In the case of an applicant applying for Medi-Cal reimbursement for nursing facility care, the statements required under Sections 14006.2 and 14006.3 shall apply, and the statement required by subdivision (a) shall not be provided.