Medi-Cal Eligibility Forms Listed by Translated Languages 

Some Medi-Cal Eligibility forms are available in one or more of the languages listed below. To view a list of forms translated into a language, click on the language below:

Arabic | Armenian | Chinese | Farsi | Hmong | Khmer | 
Korean | Laotian | Russian | Spanish | Tagalog | Vietnamese

Should you require additional assistance after reading the instructions printed on the form, contact your eligibility worker or the nearest Local County Welfare Office.

Note: The documents listed below are in Adobe Acrobat (PDF) format. You must have on your computer the Adobe Acrobat Reader to Open, View and Print the PDF document.

This page will be updated periodically. If you do not see the form translated in your language, or if the link to the form in your language is not active at present, please ask for assistance from your eligibility worker.

  

Arabic

• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Arabic)

• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals (Arabic)

• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Arabic)
• DHCS 0004 (6/07) - Request for California Birth Record (Arabic)
• DHCS 0006 (08/07) - Proof of Citizenship and Identity (Arabic) 

• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents - (Arabic)

• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements--For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application (Arabic)

• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Arabic)

• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Arabic)

• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Arabic)

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Armenian

• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Armenian)

• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals (Armenian)

• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Armenian)

• DHCS 0004 (6/07) - Request for California Birth Record (Armenian)

• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Armenian) 

• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents - (Armenian)

• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements--For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application (Armenian)

• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Armenian)

• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Armenian)

• MC 176 S (5/07) - Medi-Cal Status Report (Armenian)

• MC 210 (8/01) - Medi-Cal Mail-In Application (Armenian)
  Instructions

• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Armenian)
• MC 368 (7/03) - Notice and Supplemental Form for Express Enrollment Applicants (Armenian)
• MC 368 A (7/07) - Important Information for Medi-Cal Applicants (Armenian)
• NA Back 9 - Your Hearing Rights (Armenian)

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Chinese

• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Chinese)

• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals (Chinese)

• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Chinese)

• DHCS 0004 (6/07) - Request for California Birth Record (Chinese)

• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Chinese)

• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents - (Chinese)

• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements--For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application (Chinese)

• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Chinese)

• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Chinese)

• MC 176 S (5/07) - Medi-Cal Status Report (Chinese)
• MC 210 (8/01) - Medi-Cal Mail-In Application (Chinese)
  Instructions
• MC 210 PS (5/07) - Property Supplement (Chinese)
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Chinese)
• NA Back 9 - Your Hearing Rights (Chinese)

Farsi

• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Farsi)

• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals (Farsi)

• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Farsi)

• DHCS 0004 (6/07) - Request for California Birth Record (Farsi)

• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Farsi)

• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Farsi)

• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements--For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application (Farsi)

• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Farsi)

• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Farsi)
• MC 176 S (1/08) - Medi-Cal Status Report
• MC 210 (8/01) - Medi-Cal Mail-In Application (Farsi)
  Instructions
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Farsi)
• NA Back 9 - Your Hearing Rights (Farsi)

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Hmong

• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Hmong)

• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals (Hmong)

• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Hmong)

• DHCS 0004 (6/07) - Request for California Birth Record (Hmong)

• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Hmong) 

• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Hmong)

• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements--For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application (Hmong)

• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Hmong)

• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Hmong)
• MC 176 S (5/07) - Medi-Cal Status Report (Hmong)
• MC 210 (8/01) - Medi-Cal Mail-In Application (Hmong)
  Instructions
• MC 210 PS (5/07) - Property Supplement (Hmong)
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Hmong)
• NA Back 9 - Your Hearing Rights (Hmong)

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Khmer (Cambodian)

• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Cambodian)
• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Cambodian)
• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Cambodian)
• DHCS 0004 (6/07) - Request for California Birth Record (Cambodian)
• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Cambodian)
• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Cambodian)
• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements -- For Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families/Medi-Cal Joint Application (Cambodian)
• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Cambodian)
• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Cambodian)
• MC 176 S (5/07) - Medi-Cal Status Report (Cambodian)
• MC 210 (8/01) - Medi-Cal Mail-In Application (Cambodian)
  Instructions
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Cambodian)
Korean
• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Korean)
• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Korean)
• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Korean)
• DHCS 0004 (6/07) - Request for California Birth Record (Korean)
• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Korean)
• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Korean)
• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements for Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families (Korean)
• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Korean)
• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Korean)
• MC 176 S (1/08) - Medi-Cal Status Report
• MC 210 (8/01) - Medi-Cal Mail-In Application (Korean)
  Instructions
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Korean)
• NA Back 9 - Your Hearing Rights (Korean)

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 Laotian
• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Lao)
• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Lao)
• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Lao)
• DHCS 0004 (6/07) - Request for California Birth Record (Lao)
• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Lao)
• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Lao)
• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements -- For Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families/Medi-Cal Joint Application (Lao)
• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Lao)
• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Lao)
• MC 210 (8/01) - Medi-Cal Mail-In Application (Lao)
  Instructions
• NA Back 9 - Your Hearing Rights (Lao)

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Russian
• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Russian)
• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Russian)
• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Russian)
• DHCS 0004 (6/07) - Request for California Birth Record (Russian)
• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Russian)
• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Russian)
• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements for Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families (Russian)
• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Russian)
• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Russian)
• MC 176 S (5/07) - Medi-Cal Status Report (Russian)
• MC 210 (8/01) - Medi-Cal Mail-In Application (Russian)
  Instructions
• MC 210 PS (5/07) - Property Supplement (Russian)
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Russian)
• NA Back 9 - Your Hearing Rights (Russian)

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Spanish
• CW 2.1 NA (SP) (8/04) - Notice and Agreement ofr Child, Spousal, and Medical Support (Spanish)
• CW 2.1 Q (SP) (7/01) - Support Questionnaire (Spanish)
• CW 51 (SP) (7/01) - Child Support - Good Cause for Noncooperatio (Spanish) 
• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Spanish)
• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals (Spanish)
• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Spanish)
• DHCS 0004 (6/07) - Request for California Birth Record (Spanish)
• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Spanish)

• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents - (Spanish)

• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements--For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application (Spanish)

• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Spanish)

• DHCS 7068 (7/07) - Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives (Spanish)
• DHCS 7077 (1/08) Notice Regarding Standards for Medi-Cal Eligibility (Spanish)
• DHCS 7077 A (7/07) - Notice Regarding Transfer of a Home for Both a Married and an Unmarried Applicant/Beneficiary (Bilingual)
• DHCS 7096 (7/07) - Department of Developmental Services Waiver Referral (Spanish)
• DHCS 7102 (1/08) - Notice Regarding Standards for Medi-Cal Eligibility for Distribution by Insurers, Agents, and Brokers (Spanish)
• MC Information Notices (Spanish)
• MC 0021(4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Spanish)
• MC 14 A (7/07) - Qualified Low-income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB)(, and Qualifying Individuals (QI) Application
  County Listing (Spanish)
• MC 18 (7/07) - Important Notice About Your Medi-Cal Benefits (Bilingual)
• MC 174 (5/07) - Medi-Cal Notice to Providers - Clarification of Liability (Bilingual)
• MC 176 PA-1/PA-2 (5/07) - Property Worksheet/Assessment for Institutionalized Spouses (Bilingual)
• MC 176 S (5/07) - Medi-Cal Status Report (Spanish)
• MC 179 (1/08) - Disability Evaluation Form (Spanish)
• MC 210 (8/01) - Medi-Cal Mail-In Application (Spanish)
  Instructions
• MC 210 A (9/07) - Supplement to Statement of Facts for Retroactive Coverage/Restoration (Spanish)
• MC 210 B (8/01) - Supplement to Statement of Facts (Pickle Eligibility/Determination) (Spanish)
• MC 210 PA (5/07) - Property Assessment Statement of Facts (Spanish)
• MC 210 PS (5/07) - Property Supplement (Spanish)
• MC 210 RV (10/07) - Medi-Cal Annual Redetermination (Spanish)
• MC 210 S-C (5/07) - Additional Children (Supplement to the Medi-Cal Statement of Facts, MC 210) (Bilingual)
• MC 210 S-E (5/07) - Student Educational Expenses (Supplement to the Medi-Cal Statement of FActs, MC 210) (Spanish)
• MC 210 S-I - (5/07)Income In-Kind/Housing Verifications (Supplement to the Medi-Cal Statement of Facts, MC 210) (Bilingual)
• MC 210 S-W (7/07) - Vocational and Work History (Spanish)
• MC 212 (7/07) - Medi-Cal Residency Declaration (Bilingual)
• MC 214 (7/07) - Important Information About Residency (Spanish)
• MC 215 (7/07) - Request for Withdrawal and/or Waiver of Ten-Day Advance Notice (Spanish)
• MC 219 (10/07) - Important Information for Persons Requesting Medi-Cal (Spanish)
• MC 220 8pt (8/07) - Authorization for Release of Information - 8 point print (Spanish)
• MC 220 14pt (7/07) - Authorization for Release of Information - 14 point print (Spanish)
• MC 239 Back (C) (7/07) - Your Right to Appeal This Action (Spanish)
• MC 250 A (11/00) - Application and Statement of Facts for An individual Who is Over 18 and Under 21 and Who Was in Foster Care Placement on His or Her 18th Birthday (Spanish)
• MC 262 (6/07) - Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU) (Spanish)
• MC 263 S-R (5/07) - Statement of California Residency (Spanish)
• MC 264 (6/07) - Presumptive Eligibility Patient Fact Sheet (Spanish)
• MC 265 (6/07) - Patient Directions for Presumptive Eligibility Application (Spanish)
• MC 273 (5/07) - Work Activity Report (Spanish)
• MC 274 TB (5/07) - Medi-Cal Tuberculosis Program Application (Spanish)
• MC 306 (1/08) - Appointment of Representative (Spanish)
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Spanish)
• MC 322 (9/07) - Real and Personal Property - Supplement to Medi-Cal Mail-In Application (Spanish)
• MC 330 (6/07) - Newborn Referral (Not an Application for Medi-Cal) (Spanish)
• MC 338 Flyer (3/02) - New Medi-Cal Program for Workers with Disabilities: 250 Percent Working Disabled Program (Spanish)
• MC 354 (5/07) - Medi-Cal Contact Update (Spanish)
• MC 368 M (7/07) - Supplemental Form for Express Enrollment Applicants (Spanish)
• MC 4026 (7/07) - Request for Eligibility Limited Services (Spanish)
• NA Back 9 - Your Hearing Rights (Spanish)
• PUB 68 - Medi-Cal--What it Means to You (Spanish)
• SAWS 2 (1/07) - Statement of Facts for Cash Aid, Food Stamps, and Medi-Cal/State-Run County Medical Services Program (CMSP) (Spanish)

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Spanish Information Notice

• MC 002 Information Notice (9/07) - Summary Medi-Cal Eligibility (Spanish)
• MC 003 Information Notice (6/07)- Early and Peiodic Screening, Diagnosis, and Treatment Services (Spanish)

• MC 004 Information Notice (5/07) - Important Information for Medi-Cal Nursing Home Patients (Bilingual)

• MC 007 Information Notice (4/08) - Medi-Cal General Property Limitations (Spanish)
• MC 008 Information Notice (5/07) - Qualified Medicare Beneficiary Program (Spanish)
• MC 010 Information Notice (4/07) - Qualified Disabled Working Individual (Spanish)
• MC 013 Information Notice (5/07) - Statement of Citizenship, Alienage, and Immigration Status (Spanish)
• MC 017 Information Notice (7/07) - What You Should Know About Your Medi-Cal Disability Application (Bilingual)

 

Tagalog
• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Tagalog)
• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Tagalog)
• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Tagalog)
• DHCS 0004 (6/07) - Request for California Birth Record (Tagalog)
• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Tagalog)
• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Tagalog)
• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements for Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families (Tagalog)
• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Tagalog)
• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Tagalog)
• MC 321 (12/07) - Healthy Families/Medi-Cal Joint Application (Tagalog)
Vietnamese
• DHCS 0001 (1/08) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Vietnamese)
• DHCS 0002 (1/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Vietnamese)
• DHCS 0003 (6/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Vietnamese)
• DHCS 0004 (6/07) - Request for California Birth Record (Vietnamese)
• DHCS 0006 (8/07) - Proof of Citizenship and Identity (Vietnamese)
• DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents (Vietnamese)
• DHCS 0008 (1/08) - Proof of Citizenship and Identity Requirements for Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families (Vietnamese)
• DHCS 0009 (9/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Vietnamese)
• MC 0021 (4/07) - Medi-Cal to Healthy Families Bridging Consent Form (Vietnamese)
• MC 176 S (5/07) - Medi-Cal Status Report (Vietnamese)
• MC 210 (8/01) - Medi-Cal Mail-In Application (Vietnamese)
  Instructions
• MC 321 HFP (12/07) - Healthy Families/Medi-Cal Joint Application (Vietnamese)
• NA Back 9 - Your Hearing Rights (Vietnamese)

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