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The Medical Application Form is a crucial document for individuals and families seeking access to Medi-Cal, California's Medicaid program. This form gathers essential information about the applicant, their household, and financial status to determine eligibility for medical benefits. To begin the process, fill out the form by clicking the button below.

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The Medical Application Form is a crucial document for individuals seeking Medi-Cal benefits in California. This extensive form collects personal and family information to determine eligibility for healthcare coverage. It begins by asking for the applicant's details, including their name, address, and contact information. Next, the form requires information about family members who may require coverage, whether they are children or adults. It prompts applicants to disclose their income sources and monthly expenses, which help assess financial eligibility. Additionally, it includes questions regarding medical conditions, disabilities, and previous experiences with social services, such as cash aid or food stamps. Recognizing cultural diversity, the form also inquires about language preferences. To process the application efficiently, complete instructions are provided, emphasizing clarity and accuracy in responses. Overall, the Medical Application Form serves as a comprehensive tool to facilitate access to essential healthcare resources for families in need.

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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

Get Medical Application PDF Form

Fact Name	Description	Governing Law (for State-Specific Forms)
Purpose of the Form	The Medical Application Form is used to apply for Medi-Cal, California's Medicaid program, which provides health coverage to qualifying individuals and families.	California Welfare and Institutions Code, Sections 14000 et seq.
Eligibility Requirements	To qualify for Medi-Cal, applicants must meet certain criteria, including income limits, citizenship status, and residency requirements.	California Welfare and Institutions Code, Sections 14005 and 14006.
Information Required	Applicants must provide personal information, including income details, household composition, and health status, for all individuals applying for coverage.	California Welfare and Institutions Code, Sections 14011 et seq.
Submission Process	The form must be completed clearly in black or blue ink and submitted to the appropriate local agency; all required documentation should accompany the application.	California Code of Regulations, Title 22, Sections 50000 et seq.

Once you have gathered all necessary information, follow these steps to complete the Medical Application form. Ensuring accuracy is important, as this will help your application process smoothly.

Print clearly using black or blue ink throughout the form.
In Section 1, fill out details about the individual applying for Medi-Cal. Provide their last name, first name, middle initial, and full home address (do not use a P.O. Box unless homeless).
Add the home phone number, city, state, and zip code. Include a work phone number and a mailing address if different from the home address.
Indicate which languages the person speaks and reads best in Section 1.
In Section 2, provide information about the applicant’s family and children in their care. This includes names, relationships, addresses, gender, and marital status.
Document each individual’s date of birth and pregnancy status if applicable.
Respond to questions about disabilities and whether anyone has received cash aid, SSI, Food Stamps, or Medi-Cal previously.
Complete details about income sources and amounts in Section 4. Be sure to include how often each income is received.
List all expenses or payments in Section 5 related to child support, alimony, health insurance, etc.
Skip Section 6 only if applying solely for children under 19 or pregnant women. Otherwise, address assets like cash, checking accounts, and vehicles.
For Section 7, provide additional details for individuals wanting Medi-Cal, including Social Security numbers and place of birth.
If any assistance was received while filling out the application, note that in Section 8, providing the name of the helper.
Finally, in Section 9, all applicants must sign the form. Ensure dates and any necessary witness signatures are also completed.

What is the Medical Application form for Medi-Cal?

The Medical Application form for Medi-Cal is a crucial document used to apply for California's Medicaid program. It helps individuals determine their eligibility for health care benefits. Completing this form correctly is essential, as it collects personal information, household details, income, and other relevant data needed to assess a person's need for medical coverage. Having health care coverage can significantly affect individuals and families, making it necessary to fill out the application accurately.

Who should fill out the Medical Application form?

This form should be completed by individuals seeking Medi-Cal for themselves, their family members, or children in their care. The applicant must provide thorough details about all household members, including adults and children, regardless of whether all are applying for coverage. This inclusive approach ensures that the application accounts for everyone who may benefit from health care services under Medi-Cal.

What information is required on the Medical Application form?

When filling out the form, various personal details are necessary. Some of the required information includes the applicant’s full name, address, phone numbers, family relationships, gender, marital status, and date of birth. Additionally, information about income, expenses, assets, and any medical conditions must be included. It’s important to provide accurate and complete information since this impacts the assessment of eligibility.

Is it necessary to provide Social Security numbers on the form?

While it is very helpful to include Social Security numbers for each applicant listed on the form, individuals can still qualify for Medi-Cal even if they do not have one. In cases where an applicant does not have a Social Security number, it is essential to indicate this on the form to avoid delays in processing the application.

How can I submit the Medical Application form?

The completed Medical Application can be submitted to your local Department of Health Care Services office. It may be mailed or delivered in person. Some locations may also offer electronic submission options. Checking with your local office about the preferred method can streamline the process.

What happens after I submit the application?

After submitting the application, the local social services office will review the submitted information. They may reach out for further details or clarification if necessary. A determination regarding eligibility for Medi-Cal will be made, and the applicant will be notified of the decision. It’s important for applicants to keep track of their application status and respond promptly to any inquiries.

Can I get help filling out the form?

Yes, assistance is available for individuals who need help filling out the Medical Application form. Many community organizations, family members, or social service representatives can guide applicants through the process. Moreover, there is a section on the form where you can note who helped you, ensuring that your application remains accurate and complete.

What if I make a mistake on the form?

If a mistake is made while completing the Medical Application form, it is crucial to correct it before submitting. Striking out the error and neatly writing the correct information is generally acceptable. However, if many changes are needed or if the error could confuse the application’s purpose, it may be best to start over with a new form. Always double-check for accuracy prior to submission to minimize complications and expedite the process.

Filling out the Medical Application form can be a daunting task. Many applicants mistakenly overlook basic requirements that could delay the process. Here are seven common mistakes people make when completing this form.

The first mistake often occurs in personal information. Applicants frequently forget to include essential details, such as their complete name or the correct home address. Every section must be filled out accurately, as even a single missing digit in a phone number can lead to communication issues.

A second frequent error involves not using the specified ink color. The form explicitly states that applicants must use black or blue ink. Submitting in any other color can make the application difficult to read, potentially stalling processing.

Next, applicants often neglect to answer questions about their income. Incomplete or unclear income information can raise red flags. It is essential to list all sources of income and provide the amounts clearly. This ensures that the application accurately reflects the financial situation of the household.

A fourth mistake involves misunderstanding the relationship questions. Each applicant must accurately describe their relationship to the person seeking Medi-Cal. This section should be approached with caution. Misidentifying relationships can complicate eligibility determinations.

A fifth issue arises with supporting documents. Some applicants forget to include necessary documents such as proof of income or residency with their applications. Failing to provide these documents can lead to delays or denials of services.

Another common error is not reviewing the completed application before submission. Rushing through the application process can create unnecessary mistakes. Take the time to double-check all entries for accuracy. It’s often helpful to have someone else read through the application for clarity.

Lastly, people sometimes forget to sign and date the application. The application requires a signature to be considered complete. Failing to do so can result in immediate rejection of the form, requiring the applicant to start the process over again.

The process of applying for Medi-Cal involves several crucial documents that provide comprehensive information about the applicant and their household. Understanding these forms can streamline the application process and facilitate greater access to needed healthcare services.

Proof of Income: This document verifies the applicant's sources of income such as pay stubs, tax returns, or social security statements. It establishes eligibility based on income level.
Identification Document: A government-issued ID, like a driver's license or passport, is necessary for identity verification and may be required for all household members.
Social Security Numbers: Each family member applying for benefits must provide their Social Security number or documentation showing they are not required to have one.
Residency Verification: This can include utility bills, rental agreements, or bank statements showing the applicant's name and address to confirm California residency.
Health Insurance Information: Current health insurance details, including policy numbers and coverage type, must be included to identify any existing health benefits.
Medical Expenses Documentation: Receipts or statements for recent medical expenses may be submitted to potentially count towards the eligibility determination.
Assets Declaration Form: This form outlines the applicant's assets, such as bank accounts, property, and vehicles, which helps assess financial eligibility.
Child Support Documentation: If applicable, any legal agreements or records relating to child support payments are necessary to understand financial obligations.
Medical Application Supplement: Additional forms that may be required to provide further detail about specific medical needs or conditions affecting the applicant or their family.
Authorization for Release of Information: This form allows designated individuals or entities to access the applicant's medical or financial information, which can expedite assistance services.

Completing and submitting these associated documents alongside the Medical Application form can significantly enhance the approval process for Medi-Cal benefits. It ensures that applicants provide a full picture of their financial and health needs, ultimately aiming for timely access to vital healthcare services.

The Medical Application form is similar to several other important documents. Below are four documents that share similarities with the Medical Application form:

Food Assistance Application: Like the Medical Application form, this document collects personal information and household details to determine eligibility for food assistance programs. It also requires information about income and expenses.
Housing Assistance Application: This application gathers data about individuals and families seeking housing support. Similar to the Medical Application, it includes details about income, household composition, and housing needs to assess eligibility.
Child Care Assistance Application: This form is designed to help families apply for financial aid for child care. It mirrors the Medical Application by soliciting information about family size, income, and the specific needs of children in care.
Health Insurance Marketplace Application: The application for health insurance also collects extensive personal and financial information. Much like the Medical Application, it evaluates eligibility for various health coverage options based on reported income and household composition.

Things to Do:

Print clearly and use black or blue ink only.
List the full names and relationships of all family members applying for Medi-Cal.
Provide accurate information regarding income and expenses.
Ensure all sections are completed, especially personal details and necessary signatures.
Double-check the form for completeness before submission.

Things Not to Do:

Avoid using a P.O. Box for the home address unless homeless.
Do not leave any questions blank; answer all that are applicable.
Refrain from providing false information or guessing on answers.
Do not submit the form without ensuring you have included all required documents.
Do not forget to sign and date the application when completed.

Misconception 1: The Medical Application form is only for low-income individuals.

Many people believe that Medi-Cal is only for the very poor. In reality, Medi-Cal provides health care coverage to a wide range of individuals, including some who may have higher income levels based on family size and specific circumstances.

Misconception 2: You must be a U.S. citizen to apply.

A common misconception is that only U.S. citizens can access Medi-Cal. Non-citizens may also qualify for coverage under certain conditions, such as being a lawful permanent resident or a child under 19.

Misconception 3: You cannot apply if you have assets.

Some think that having assets disqualifies them from applying for Medi-Cal. While there are asset limits, you can still apply even if you own a home or have savings, as long as you meet the eligibility criteria.

Misconception 4: Pregnant women automatically qualify for Medi-Cal.

It is often believed that all pregnant women qualify for Medi-Cal. Eligibility is based on income level. Pregnant women need to complete an application to see if they meet the income requirements.

Misconception 5: You cannot get help filling out the application.

Many assume they must fill out the application alone. You can receive help from family members, friends, or advocates. There are resources available to guide you through the process.

Misconception 6: You can submit the application without providing all required information.

Some believe they can turn in an incomplete application. However, providing complete and accurate information is essential for determining eligibility. Missing information could delay processing or result in denial.

Misconception 7: Once you're accepted, you’ll never need to renew.

Many think that if they receive Medi-Cal once, renewal isn’t necessary. In reality, beneficiaries must renew their coverage regularly to ensure they still qualify based on current circumstances.

Misconception 8: Medi-Cal will cover any medical expense.

People sometimes believe that all medical costs are covered. While Medi-Cal provides extensive coverage, certain services may not be included. It’s important to review what is covered to avoid unexpected costs.

Filling out the Medical Application form for Medi-Cal can feel overwhelming, but it is essential to approach it step by step. Here are some key takeaways to keep in mind as you complete this important task.

Clarity is Key: Ensure that each section of the application is filled out clearly. Use black or blue ink and print legibly. This will help avoid any misunderstandings about the information you provide.
Provide Complete Information: Gather all necessary details about yourself and the individuals in your care before starting. This includes names, addresses, relationships, and income sources. Complete information will streamline the review process.
Check Your Eligibility: Before filling out the form, familiarize yourself with the eligibility requirements for Medi-Cal. Certain factors, such as income and residency status, will impact your application.
Maintain Accuracy: Double-check all information for accuracy. Inconsistent or incorrect details can lead to delays or denials in receiving coverage. Take your time to provide correct dates, names, and numbers.
Signature Matters: Do not forget to sign the application. The final section requires your signature to certify that all information is true. Without it, the application may be considered incomplete.

Taking the time to understand these key points will enhance your confidence while filling out the Medi-Cal application and help ensure that you navigate the process smoothly.

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