TEAR HERE State of California - Health and Human Services Agency Department of Health Care Services APPLICATION FOR MEDI-CAL To complete this form use the instructions. 59 Check this box if you do not want Medi-Cal to share your child s application with the low-cost Healthy Families if your child does not qualify for no-cost Medi-Cal. K I got help from give name of person when I filled out this application. I agree that the local social services office may give them information about the...
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Who needs an Application for Medi-Cal form?

Any low-income person (or families, seniors, homeless people, persons with disabilities, children in foster care and others) living in California can file a Medi-Cal Application to obtain benefits of California Medicaid welfare program.

What is the Application for Medi-Cal for?

This Medi Cal online application form provides detailed information about the person applying for assistance. Including person’s disability status, information about children of an applicant, person’s income, expenses and insurance information.

Is the Application for Medi-Cal accompanied by other forms?

You are not required to accompany the submission of the Medi Cal application form with any documents. But further, you have to be ready to provide all necessary documents confirming your low-income status.

When is Application for Medi-Cal form due?

Dates for the submission of this form are not set. You can apply for participation in the Medi-Cal program at any time.

How do I fill out Application for Medi-Cal form?

The applicant must provide personal information about themselves as well as to answer questions on the following topics:

  • Family and children;
  • Income money for the whole family and in person;
  • Expenses/cost paid for the whole family and in person;
  • Person’s language and cultural characteristics.

Where do I send Application for Medi-Cal form?

Completed and signed application should be directed to Covered California, P.O. Box 989725, West Sacramento, CA 95798-9725.

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