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APPLICATION FOR MEDI-CAL
MIDDLE INITIALFIRST NAME
HOME ADDRESS (NUMBER AND STREET).
DO NOT LIST A P.O. BOX UNLESS HOMELESS
APARTMENT NUMBERHOME PHONE #
WORK PHONE #
MESSAGE PHONE #
MAILING ADDRESS (IF DIFFERENT FROM ABOVE) OR P.O. BOX
WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST
WHAT LANGUAGE DO YOU READ BEST
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
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.
MC 210 08/01
State of California - Health and Human Services AgencyDepartment of Health Services
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