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TEAR HERE

TEAR HERE

State of California - Health and Human Services Agency

Department of Health Services

APPLICATION FOR MEDI-CAL

To complete this form, use the instructions. Print clearly. Use black or blue ink only.

SECTION 1

Tell us about the person who wants Medi-Cal for themselves, their family or children in their care.

1

LAST NAME

FIRST NAME

MIDDLE INITIAL

2

HOME ADDRESS (NUMBER AND STREET). DO NOT LIST A P.O. BOX UNLESS HOMELESS 3 APARTMENT NUMBER

4 HOME PHONE #

5

CITY/STATE

6

COUNTY

7 ZIP CODE

() 8 WORK PHONE #

9

MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OR P.O. BOX

10 APARTMENT NUMBER

() 11 MESSAGE PHONE #

12 CITY

() 13 ZIP CODE

14A WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST?

14B WHAT LANGUAGE DO YOU READ BEST?

SECTION 2

Tell us about the person listed in Section 1, his or her family and the children they care for, even if they don’t want coverage.

Adult 1/Self

Adult 2

Child 1

Child 2

Child 3

15

Name:

Last

First

Middle

16

Relationship to person in Section 1.

17

If address where living is not the same as listed in Section 1, put address where living:

18

Gender:

Male Female

Male Female

Male Female

Male Female

Male Female

19

Marital Status:

20

Name of spouse(s) of married minors in the home.

21

Date of Birth:

Single

Single

Single

Single

Single

Married

Married

Married

Married

Married

Separated

Separated

Separated

Separated

Separated

Widowed

Widowed

Widowed

Widowed

Widowed

Divorced

Divorced

Divorced

Divorced

Divorced

MO

/

DAY

/

YR

MO

/

DAY

/

YR

MO

/

DAY

/

YR

MO

/

DAY

MO

/

DAY

/

YR

/

YR

22

23

Pregnant:

Due Date:

Has a physical, mental or emotional disability?

Disability expected to last:

Yes No

Yes No

Yes No

Yes No

Yes No

30 Days or More

30 Days or More

30 Days or More

30 Days or More

30 Days or More

12 Months or More 12 Months or More 12 Months or More 12 Months or More 12 Months or More

Yes No / /

MO

DAY

YR

Yes No / /

MO

DAY

YR

Yes No / /

MO

DAY

YR

Yes No / /

MO

DAY

YR

Yes No / /

MO

DAY

YR

MC 210 08/01 APPLICATION

A1

CONTINUED

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