Medical Details

Are you looking for a new or different job in the medical industry? Do you need to fill out a medical application form? If so, you've come to the right place. In this blog post, we will provide you with all the information you need to complete a medical application form successfully. We will discuss the types of information that are typically requested on these forms, as well as some tips for ensuring that your application is accurate and informative.

Before you fill out medical application, you'll want to understand more concerning the type of form you will use.

QuestionAnswer
Form NameMedical Application
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmedical, medi cal application form online, medi cal gov, medical application form

Form Preview Example

TEAR HERE

State of California - Health and Human ServicesAgency

Department of Health Care 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

 

FIRST NAME

 

 

 

 

MIDDLE INITIAL

 

 

 

 

 

 

 

 

 

 

 

 

2

 

HOMEADDRESS(NUMBERANDSTREET).DO NOT LIST A P.O. BOX UNLESSHOMELESS

3

APARTMENT NUMBER

 

4

HOME PHONE #

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

5

 

CITY/STATE

6

COUNTY

 

 

7

ZIP CODE

 

8

WORK PHONE #

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

9

 

MAILINGADDRESS (IF DIFFERENT FROMABOVE) OR P.O. BOX

 

 

10

APARTMENT NUMBER

 

11

MESSAGE PHONE #

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

12

 

CITY

 

 

 

 

 

 

 

13

ZIP CODE

 

 

 

 

 

 

 

 

 

 

 

14A

WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST?

 

 

14B

WHAT LANGUAGE DO YOU READ BEST?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEAR HERE

SECTION 2 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

Adult 2

Child 1

Child 2

Child 3

 

 

 

 

 

 

15

Name:

 

 

 

 

 

 

Last

 

 

 

 

 

 

 

 

 

 

First

Middle

16Relationship to person in Section 1.

17If address where living is not the same as listed in Section 1, put address where living:

18

Gender:

Male Female

Male Female

Male Female

Male Female Male Female

 

 

19 Marital Status:

Single

Single

Single

Single

Single

 

Married

Married

Married

Married

Married

 

Divorced

Divorced

Divorced

Divorced

Divorced

 

Separated

Separated

Separated

Separated

Separated

 

Widowed

Widowed

Widowed

Widowed

Widowed

20Name of spouse(s) of married minors in the home.

21

Date of Birth:

/

/

/

/

/

/

/

/

/

/

 

 

 

 

 

MO DAY

YR

MO

DAY YR

MO

DAY YR

MO

DAY YR

MO

DAY YR

 

 

 

 

 

 

 

 

 

 

 

 

22

Pregnant:

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

 

Due Date:

/

/

/

/

/

/

/

/

/

/

MO

DAY

YR

MO

DAY YR

MO

DAY YR

MO

DAY YR

MO

DAY YR

23

Has a physical, mental

Yes No

Yes No

Yes No

Yes No

Yes No

 

or emotional disability?

 

 

 

 

 

 

 

Disability expected

30 Days or More

30 Days or More

30 Days or More

30 Days or More

30 Days or More

 

to last:

12 Months or More

12 Months or More

12 Months or More

12 Months or More

12 Months or More

 

 

MC 210 2/10

A1

CONTINUED

APPLICATION

SECTION 2 Continued

Adult 1/Self

Adult 2

Child 1

Child 2

Child 3

 

24Hasanyoneeverreceived

cash aid, SSI, Food

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Stamps orMedi-Cal?

 

 

 

 

 

 

 

 

 

 

If “Yes,” under what name?

25Medi-Calbenefitscard number(BIC),ifyouhaveit:

26

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wants medical benefits?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

27Do you own or are

 

 

you buying a home

 

Yes

No

 

 

Yes

No

 

 

Yes

No

 

Yes

No

 

Yes

No

 

 

outside California?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 3

 

Answer for all children in Section 2.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child 3

 

 

 

 

 

 

 

Unborn

 

 

 

Child 1

 

 

 

 

 

 

Child 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

28

 

Mother’s Name:

 

 

 

 

Mother’s Name:

 

 

 

 

Mother’s Name:

 

 

 

 

 

 

 

Mother’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is Mother:

 

 

 

 

Is Mother:

 

 

 

 

 

 

Is Mother:

 

 

 

 

 

 

 

Is Mother:

 

 

 

 

 

 

Employed

 

Employed

Employed

 

 

Employed

 

Disabled

 

Unemployed

 

 

Disabled

Unemployed

 

Disabled

 

Unemployed

 

Disabled

Unemployed

 

Deceased

 

Absent

 

 

Deceased

Absent

 

Deceased

 

Absent

 

 

 

 

 

 

 

 

 

 

 

 

 

29

 

Father’s Name:

 

 

 

 

 

Father’s Name:

 

 

 

 

Father’s Name:

 

 

 

 

 

 

 

Father’s Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is Father:

 

Employed

 

Is Father:

Employed

Is Father:

 

Employed

 

 

Is Father:

Employed

 

Disabled

 

Unemployed

 

 

Disabled

Unemployed

 

 

Disabled

 

Unemployed

 

Disabled

Unemployed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Deceased

 

Absent

 

 

Deceased

Absent

 

 

Deceased

 

Absent

 

 

 

Deceased

Absent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 4

List allincome/money received by persons listed in Section 2.

 

 

 

 

 

 

 

30

 

 

31

SOURCE OF INCOME/

32

HOW MUCH

 

NAME OF PERSON RECEIVING

 

MONEY RECEIVED

 

INCOME/MONEY

 

INCOME/MONEY

 

 

 

 

(Employment, social security)

 

IS RECEIVED

 

 

 

 

 

 

 

 

 

 

 

 

33HOW OFTEN INCOME/

MONEY RECEIVED

(Monthly, bimonthly, weekly, biweekly, daily)

SECTION 5 Give information about the listed expenses/cost paid by allpersons listed in Section 2.

TYPE OF PAYMENT

34

NAME OF

35

MONTHLY

YOUR FAMILYMAKES

PERSON WHO PAYS

AMOUNT PAID

Child Support

Alimony

Other Health

Insurance Premium

Medicare Premium

36

CHILD CARE OR

37

AGE

38

NAME OF

39

MONTHLY

 

DEPENDENT CARE

 

 

PERSON WHO PAYS

AMOUNT PAID

(List child’s or dependent’s name)

 

 

 

 

 

 

 

 

1.

2.

3.

4.

MC 210 2/10

A2

APPLICATION

TEAR HERE

SECTION 6

Skip this Section if you are only applying for children under 19 and/or pregnant women

 

(pregnancy related services only).

Otherwise answer for all persons listed in Section 2.

40Does anyone have cash or uncashed checks?

If “Yes,” list amount here

 

(See instructions)

41Does anyone have a checking, savings account, or life insurance? (See instructions)

42Is there one car or more in the household? (See instructions)

43Does anyone have a court ordered settlement or judgement? (See instructions)

44Does anyone have Long-Term Care insurance? (See instructions)

45Does anyone own any items such as stocks, bonds, retirement funds, trusts, real estate, motor vehicles for a business, business accounts, promissory notes, mortgages, deeds of trust, recreational vehicles, burial trusts or funds, annuities, jewelry (not heirloom or wedding), oil or mineral rights? (See instructions)

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

46

Has anyone listed on this form transferred, sold, traded or given away any items such as those

Yes

No

 

listed above in the last 30 months? (See instructions)

 

 

 

 

 

 

 

 

 

 

47Have any items listed in this section been spent or used as security for medical costs?

(See instructions)

Yes

No

TEAR HERE

SECTION 7

Answer only for persons who want Medi-Cal.

 

 

 

 

 

 

 

 

Adult 1/Self

Adult 2

Child 1

Child 2

Child 3

48Social Security #:

You may be able to receive Medi-Cal even if you do not have a Social Security Number.

49Place of Birth:

State or Country.

50

U.S. Citizen or National?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

If “No,” write in date of

 

/

 

/

 

/

 

/

 

/

 

/

 

/

 

/

 

/

 

/

 

entry into U.S.

 

 

 

 

 

 

 

 

 

 

 

MO

DAY

YR

MO

DAY

YR

MO

DAY

YR

MO

DAY

YR

MO

DAY

YR

 

 

51Living in a Long-Term

 

Care or Board and

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

Care Facility?

 

 

 

 

 

 

 

 

 

 

 

If “Yes,” name of

 

 

 

 

 

 

 

 

 

 

 

facility:

 

 

 

 

 

 

 

 

 

 

 

Do you intend to

 

 

 

 

 

 

 

 

 

 

 

return home?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

Do you intend to

 

 

 

 

 

 

 

 

 

 

 

return home within

 

 

 

 

 

 

 

 

 

 

 

six months?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

52

Has health/dental or

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

vision coverage?

 

 

 

 

 

 

 

 

 

 

 

53Had medical expenses within the 3 months

 

before the month you

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

applied and want Medi-

 

 

 

 

 

 

 

 

 

 

 

Cal for those expenses.

 

 

 

 

 

 

 

 

 

 

54

Lawsuit pending due

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

to accident or injury?

 

 

 

 

 

 

 

 

 

 

 

MC 210 2/10

A3

CONTINUED

APPLICATION

SECTION 7

Continued

 

 

 

 

 

Adult 1/Self

Adult 2

Child 1

Child 2

Child 3

55

Current or past

Yes No

Yes No

Yes No

Yes No

Yes No

 

U.S. Military Service

 

Self

Self

Self

Self

Self

 

for adults, spouse or

 

Spouse

Spouse

Spouse

Spouse

Spouse

 

child’s parents?

 

 

 

 

 

 

 

 

Parent

Parent

Parent

Parent

Parent

56

Ethnicity (race):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(optional)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

57

In school full time?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

 

 

58Living away from

home?

 

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 8

Information Release (Optional).

 

 

 

 

 

 

 

 

 

 

 

 

59Check 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.

60

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 status of this application. Applicant please initial

SECTION 9 Signature and Certification.

61I declare under penalty of perjury under the laws of the State of California that the answers I have given in this application, and the documents given are correct and true to the best of my knowledge and belief.

I declare that I have read and understand the application instructions, the declarations, and all information printed on this application.

Signature

 

 

Date

 

 

 

 

Witness Signature(If person signed with a mark)

 

 

Date

 

 

 

 

Signature of person helpingApplicant fill out the form

Telephone Number

Relationship toApplicant

Date

 

 

 

 

Signature of person acting forApplicant/Beneficiary

Telephone Number

Relationship toApplicant

Date

For information about any of the following programs, check the box(es) below and

information will be sent to you. Visit our website, www.dhcs.ca.gov

Personal Care Service Program (PCSP).Aprogram for in-home care.

Access for Infants, and Mothers (AIM).Aprogram to help pregnant women with moderate income

obtain health care.

Woman, Infants and Children Nutrition Program (WIC).Anutrition program for pregnant and

postpartum women and children under 5.

Family Planning

Child Health and Disability Prevention (CHDP) program. Preventive healthcare for children and youth.

Do you want your children or youth referred to the CHDP program for follow-up?

Yes

No

MC 210 2/10

A4

APPLICATION