Question	Answer
Form Name	Medi Cal Redetermination Form
Form Length	4 pages
Fillable?	Yes
Fillable fields	111
Avg. time to fill out	23 min 16 sec
Other names	medical redetermination form, how to fill out medi cal annual redetermination form, medi cal redetermination, dpss lacounty gov annual redetermination en español

Case Number (optional)	Social Security Number (optional)

Print Your Full Name (if you have not moved, put address label here if one is provided)	Birth Date (optional) (mm/dd/yyyy)

Current Street Address, Apartment Number ❑ (check here if address is new)	City/State	Zip Code

Mailing Address (if different from above)	City/State	Zip Code


(b) Do you or any family member in the home get rent, utilities, food, or clothing entirely free?			❑ Yes ❑ No
If yes, who?
What was free?⁜
(c) Was the free rent, utilities, food, or clothing received in exchange for work done?			❑ Yes ❑ No

Section 2. Expenses and Deductions
Do you or any family member in the home pay for child or adult care, health insurance or Medicare
premiums, court-ordered child support or alimony, or educational expenses?	❑ Yes ❑ No
If yes, complete below and list each expense/deduction on a separate line.
Attach proof of expenses/deductions.


Section 3. Other Health Insurance
(a) Did you or any family member have a change in, or get new health, dental, vision, or Medicare
coverage or insurance within the last 12 months?					❑ Yes ❑ No
If yes, who has the coverage/insurance?
Which type of coverage/insurance?
(b) Is any family member living in the home receiving kidney dialysis-related services?					❑ Yes ❑ No
If yes, who?⁜
(c) Has any family member living in the home received an organ transplant within the last 2 years?					❑ Yes ❑ No
If yes, who?⁜

(b) Does anyone in the home want Medi-Cal who is not already receiving it?						❑ Yes ❑ No
If yes, who?⁜ ؠ

(c) If a new baby is in home, where was the baby’s place of birth?		⁜ \|		\|
	City		State		Country

Section 4. Living Situation continued
(d) Did anyone in the home get inpatient care in a nursing facility or medical institution?⁜		❑ Yes ❑ No
If yes, who?⁜
		❑ Yes ❑ No
(e) Is anyone in the home pregnant?		❑ Yes ❑ No
If yes, who?
Number of babies expected	Due date: ⁜

for medical costs?	❑ Yes ❑ No
Note: If you have answered “yes” to questions (b) or (c), you will also have to fill out a property
supplement form, submit the form to the county and provide verification.
Section 6. Immigration or Citizenship Status Change
Has there been a change in immigration or citizenship status for anyone in the home that has Medi-Cal
or wants Medi-Cal within the last 12 months? (If your immigration status has changed, you might qualify for
full scope Medi-Cal benefits.)	❑ Yes ❑ No
If yes, list the name(s) below and send proof of new status.

Section 7. Blindness/Disability/Incapacity
(a)	Do you or any family member in the home have a physical or emotional condition that makes it
	difficult to work, take care of personal needs, or take care of your children? ⁜	❑ Yes ❑ No
	If yes, who?
(b) Was the physical, mental, or health condition a result of an injury or accident?		❑ Yes ❑ No
	If yes, explain

(a)	Check this box if you do not want your child’s information shared with the low-cost Healthy
	Families Program if your child gets Medi-Cal with a share of cost. ❑
(b) Do you want information on the no-cost health program for children under 21 (Child Health			❑ Yes ❑ No
	and Disability Prevention Program, also known as CHDP?)		❑ Yes ❑ No
(c) Do you want information on the no-cost supplemental food program for pregnant or breast
	feeding women and children under 5 (Women, Infants, and Children Program, also known
	as WIC)?		❑ Yes ❑ No
(d) Do you want information on the Personal Care Services Program, an in-home care program
	for aged, blind, or disabled persons (also known as In-Home Supportive Services)?	⁜	❑ Yes ❑ No

Daytime or Message Telephone Number	Home Telephone Number ❑ (check here if new number)

Signature of Witness (if signed by a mark), Interpreter or Person Assisting

Medi Cal Redetermination Form – Fill Out and Use This PDF

Medi Cal Redetermination Form PDF Details