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Application for Medi Cal State of California


Application for Medi Cal State of California
Application for Medi Cal State of California
APPLICATION FOR MEDI-CAL
MIDDLE INITIALFIRST NAME
LAST NAME
HOME ADDRESS (NUMBER AND STREET).
DO NOT LIST A P.O. BOX UNLESS HOMELESS
APARTMENT NUMBER HOME PHONE #
( )
WORK PHONE #
( )
MESSAGE PHONE #
( )
APARTMENT NUMBER
CITY/STATE
COUNTY
ZIP CODE
MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OR P.O. BOX
ZIP CODE
CITY
1
2
5
9
12
10
13
11
14A
6
7
3
4
8
WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST
WHAT LANGUAGE DO YOU READ BEST
14B
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
their care.
SECTION 1
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.
SECTION 2
MC 210 08/01
APPLICATION
CONTINUED
A1
State of California - Health and Human Services Agency Department of Health Services
TEAR HERETEAR HERE
Name:
15
16
17
Adult 1/Self Adult 2
Child 1
Child 3
Child 2
22
21
18
Last
First
Middle
23
If address where living
is not the same as
listed in Section 1, put
address where living:
Gender:
Date of Birth:
Pregnant:
Male Female
/ /
MO DAY YR
Yes No
/ /
MO DAY YR
Due Date:
Disability expected
to last:
Yes No
30 Days or More
12 Months or More
Has a physical, mental
or emotional disability
Single
Married
Divorced
Separated
Widowed
Male Female
/ /
MO DAY YR
Yes No
/ /
MO DAY YR
Yes No
30 Days or More
12 Months or More
30 Days or More
12 Months or More
30 Days or More
12 Months or More
30 Days or More
12 Months or More
Single
Married
Divorced
Separated
Widowed
Male Female
/ /
MO DAY YR
Yes No
/ /
MO DAY YR
Yes No
Single
Married
Divorced
Separated
Widowed
Male Female
/ /
MO DAY YR
Yes No
/ /
MO DAY YR
Yes No
Single
Married
Divorced
Separated
Widowed
Male Female
/ /
MO DAY YR
Yes No
/ /
MO DAY YR
Yes No
Single
Married
Divorced
Separated
Widowed
Marital Status:
19
20
Name of spouse(s)
of married minors in
the home.
Relationship to person
in Section 1.
Application for Medi Cal State of California
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