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.
Tell us about the person who wants Medi-Cal for themselves, their family or children in
HOME ADDRESS (NUMBER AND STREET). DO NOT LIST A P.O. BOX UNLESS HOMELESS
3 APARTMENT NUMBER
4 HOME PHONE #
7 ZIP CODE
8 WORK PHONE #
10 APARTMENT NUMBER
11 MESSAGE PHONE #
9 MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OR P.O. BOX
14A WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST?
13 ZIP CODE
14B WHAT LANGUAGE DO YOU READ BEST?
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.
16 Relationship to person