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Question	Answer
Form Name	Medical Application
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	medical, medi cal application form online, medi cal gov, medical application form

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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?

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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.

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:	/	/	/	/	/	/	/	/	/	/
	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:

Wants medical benefits?

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

27Do you own or are

you buying a home

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

outside California?

SECTION 3

Answer for all children in Section 2.

Child 3

Unborn

Child 1

Child 2

Mother’s Name:

Is Mother:

❑

Employed

❑

Employed

❑

Employed

❑

Employed

❑

Disabled

❑

Unemployed

❑

Disabled

❑

Unemployed

❑

Disabled

❑

Unemployed

❑

Disabled

❑

Unemployed

❑

Deceased

❑

Absent

❑

Deceased

❑

Absent

❑

Deceased

❑

Absent

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			MONEY RECEIVED		INCOME/MONEY
	INCOME/MONEY			(Employment, social security)		IS RECEIVED
				(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)				PERSON WHO PAYS		AMOUNT PAID
(List child’s or dependent’s name)

MC 210 2/10	A2
APPLICATION

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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

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

❑

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SECTION 7	Answer only for persons who want Medi-Cal.
	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.

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.

DAY

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?	❑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?	❑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

Ethnicity (race):

(optional)

In school full time?

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

58Living away from

home?

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

Yes

❑

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.

❑

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

Adult 1/Self