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San Joaquin County Human Services Agency fax number

(209) 932-2691

QMB/SLMB/QI Program (Medicare Savings Program)

Used for: Submitting Medicare Savings Program applications and related documents

Fax destination details

Department
QMB/SLMB/QI Program (Medicare Savings Program)
Purpose
Submitting Medicare Savings Program applications and related documents
Form
QMB/SLMB/QI Application Form (C01-48) — Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Application Form
Address
333 East Washington Street, Stockton, CA 95201-3006
Voice phone
209-468-1357

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  • Check the organization website or call its main line for the current fax number.
  • Include a cover sheet and any case, member, claim, or form reference required.
  • Keep the delivery confirmation with your submission records.

Instructions for completing the QMB/SLMB/QI application are provided in the C01-48 form PDF; county coordinators’ list MC14a-CntyList references the program.

Official form instructions are published as a downloadable file on the organization's website.

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