Application for Medi Cal State of CaliforniaApplication for Medi Cal State of CaliforniaApplication for Medi Cal State of California
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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

2

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

5

CITY/STATE

FIRST NAME

MIDDLE INITIAL

3 APARTMENT NUMBER

4 HOME PHONE #

7 ZIP CODE

8 WORK PHONE #

10 APARTMENT NUMBER

11 MESSAGE PHONE #

(

6 COUNTY

)

(

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

)

(

14A WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST?

SECTION 2

)

13 ZIP CODE

12 CITY
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.
Adult 1/Self

15 Name:

Adult 2

Child 1

Child 3

Child 2

Last
First
Middle

16 Relationship to person

in