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.
Question | Answer |
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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 |
TEAR HERE
State of California - Health and Human ServicesAgency |
Department of Health Care Services |
APPLICATION FOR
To complete this form, use the instructions. Print clearly. Use black or blue ink only.
SECTION 1 Tell us about the person who wants
1 |
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LAST NAME |
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FIRST NAME |
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MIDDLE INITIAL |
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HOMEADDRESS(NUMBERANDSTREET).DO NOT LIST A P.O. BOX UNLESSHOMELESS |
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APARTMENT NUMBER |
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HOME PHONE # |
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CITY/STATE |
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COUNTY |
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ZIP CODE |
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WORK PHONE # |
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MAILINGADDRESS (IF DIFFERENT FROMABOVE) OR P.O. BOX |
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APARTMENT NUMBER |
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MESSAGE PHONE # |
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CITY |
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ZIP CODE |
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14A |
WHAT LANGUAGE/DIALECT DO YOU SPEAK BEST? |
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14B |
WHAT LANGUAGE DO YOU READ BEST? |
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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.
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Adult 1/Self |
Adult 2 |
Child 1 |
Child 2 |
Child 3 |
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Name: |
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Last |
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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 |
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19 Marital Status: |
❑ Single |
❑ Single |
❑ Single |
❑ Single |
❑ Single |
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❑ Married |
❑ Married |
❑ Married |
❑ Married |
❑ Married |
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❑ Divorced |
❑ Divorced |
❑ Divorced |
❑ Divorced |
❑ Divorced |
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❑ Separated |
❑ Separated |
❑ Separated |
❑ Separated |
❑ Separated |
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❑ Widowed |
❑ Widowed |
❑ Widowed |
❑ Widowed |
❑ Widowed |
20Name of spouse(s) of married minors in the home.
21 |
Date of Birth: |
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MO DAY |
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MO |
DAY YR |
MO |
DAY YR |
MO |
DAY YR |
MO |
DAY YR |
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Pregnant: |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
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Due Date: |
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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 |
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or emotional disability? |
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Disability expected |
❑ 30 Days or More |
❑ 30 Days or More |
❑ 30 Days or More |
❑ 30 Days or More |
❑ 30 Days or More |
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to last: |
❑12 Months or More |
❑12 Months or More |
❑12 Months or More |
❑12 Months or More |
❑12 Months or More |
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MC 210 2/10 |
A1 |
CONTINUED ➥ |
APPLICATION |
SECTION 2 Continued |
Adult 1/Self |
Adult 2 |
Child 1 |
Child 2 |
Child 3 |
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24Hasanyoneeverreceived
cash aid, SSI, Food |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
Stamps |
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If “Yes,” under what name?
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Wants medical benefits? |
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Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
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Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
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27Do you own or are
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you buying a home |
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Yes |
❑ |
No |
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Yes |
❑ |
No |
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Yes |
❑ |
No |
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❑ |
Yes |
❑ |
No |
❑ |
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Yes |
❑ |
No |
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outside California? |
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SECTION 3 |
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Answer for all children in Section 2. |
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Child 3 |
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Unborn |
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Child 1 |
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Child 2 |
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28 |
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Mother’s Name: |
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Mother’s Name: |
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Mother’s Name: |
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Mother’s Name: |
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Is Mother: |
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Is Mother: |
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Is Mother: |
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Is Mother: |
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❑ |
Employed |
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❑ |
Employed |
❑ |
Employed |
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❑ |
Employed |
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❑ |
Disabled |
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❑ |
Unemployed |
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❑ |
Disabled |
❑ |
Unemployed |
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❑ |
Disabled |
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❑ |
Unemployed |
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❑ |
Disabled |
❑ |
Unemployed |
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❑ |
Deceased |
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❑ |
Absent |
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❑ |
Deceased |
❑ |
Absent |
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❑ |
Deceased |
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❑ |
Absent |
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29 |
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Father’s Name: |
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Father’s Name: |
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Father’s Name: |
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Father’s Name: |
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Is Father: |
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❑ |
Employed |
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Is Father: |
❑ |
Employed |
Is Father: |
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❑ |
Employed |
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Is Father: |
❑ |
Employed |
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❑ |
Disabled |
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❑ |
Unemployed |
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❑ |
Disabled |
❑ |
Unemployed |
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❑ |
Disabled |
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❑ |
Unemployed |
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❑ |
Disabled |
❑ |
Unemployed |
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❑ |
Deceased |
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❑ |
Absent |
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❑ |
Deceased |
❑ |
Absent |
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❑ |
Deceased |
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❑ |
Absent |
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❑ |
Deceased |
❑ |
Absent |
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SECTION 4 |
List allincome/money received by persons listed in Section 2. |
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30 |
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31 |
SOURCE OF INCOME/ |
32 |
HOW MUCH |
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NAME OF PERSON RECEIVING |
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MONEY RECEIVED |
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INCOME/MONEY |
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INCOME/MONEY |
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(Employment, social security) |
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IS RECEIVED |
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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 |
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DEPENDENT CARE |
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PERSON WHO PAYS |
AMOUNT PAID |
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(List child’s or dependent’s name) |
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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 |
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(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 |
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(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
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 |
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listed above in the last 30 months? (See instructions) |
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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 |
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Adult 1/Self |
Adult 2 |
Child 1 |
Child 2 |
Child 3 |
48Social Security #:
You may be able to receive
49Place of Birth:
State or Country.
50 |
U.S. Citizen or National? |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
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If “No,” write in date of |
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entry into U.S. |
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MO |
DAY |
YR |
MO |
DAY |
YR |
MO |
DAY |
YR |
MO |
DAY |
YR |
MO |
DAY |
YR |
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51Living in a
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Care or Board and |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
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Care Facility? |
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If “Yes,” name of |
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facility: |
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Do you intend to |
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return home? |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
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Do you intend to |
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return home within |
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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 |
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vision coverage? |
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53Had medical expenses within the 3 months
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before the month you |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
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applied and want Medi- |
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Cal for those expenses. |
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54 |
Lawsuit pending due |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
❑Yes |
❑ No |
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to accident or injury? |
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MC 210 2/10 |
A3 |
CONTINUED ➥ |
APPLICATION |
SECTION 7 |
Continued |
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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 |
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U.S. Military Service |
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❑Self |
❑Self |
❑Self |
❑Self |
❑Self |
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for adults, spouse or |
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❑Spouse |
❑Spouse |
❑Spouse |
❑Spouse |
❑Spouse |
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child’s parents? |
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❑Parent |
❑Parent |
❑Parent |
❑Parent |
❑Parent |
56 |
Ethnicity (race): |
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(optional) |
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57 |
In school full time? |
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❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
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58Living away from
home? |
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❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
❑ |
Yes |
❑ |
No |
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SECTION 8 |
Information Release (Optional). |
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59Check this box if you do not want
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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.
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Witness Signature(If person signed with a mark) |
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Signature of person helpingApplicant fill out the form |
Telephone Number |
Relationship toApplicant |
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Signature of person acting forApplicant/Beneficiary |
Telephone Number |
Relationship toApplicant |
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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 |
❑ 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
❑Yes |
❑No |
MC 210 2/10 |
A4 |
APPLICATION |