Medi-Cal Eligibility Forms available in Translated Languages 

Listed below are Medi-Cal Eligibility forms available in one or more languages. 

Arabic | Armenian | Chinese | English | 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 are unable to locate a form, or if the link to the form is not working, please ask for assistance from your eligibility worker.

  

Arabic

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

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

• DHCS 0003 (6/07) (Ara) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Arabic)
• DHCS 0004 (6/07) (Ara) - Request for California Birth Record (Arabic)
• DHCS 0005 (2/08) (Ara) - Reciept of Citizenship or Identity Documents (Arabic)
• DHCS 0006 (8/07) (Ara) - Proof of Citizenship and Identity (Arabic) 

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

• DHCS 0008 (1/08) (Ara) - 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) (Ara) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Arabic)

• DHCS 0011 (6/08) (Ara) - Proof of Acceptable Citizenship or Identity Documents (Arabic)

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

• MC 176 S (3/09) (Ara) - Medi-Cal Status Report (Arabic)

• MC 210 RV (05/11) (Ara) - Medi-Cal Annual Redetermination (Arabic)

• MC 223 C (06/11) (Ara) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Arabic)

• MC 239 DRA-6 (2/10) (Ara) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Arabic)

• MC 264 (9/11) (Ara) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Arabic)

• MC 321 HFP (1/10) (Ara) - Healthy Families/Medi-Cal Joint Application (Arabic) (Not DHCS)

• MC 371 (6/09) (Ara) - Additional Family Members Requesting Medi-Cal (Arabic)

• MC 372 (9/09) (Ara) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Arabic)

• MC 4034 (1/08) (Ara) - Language Services Notice (Multilingual) 

• MC 4035 (4/08) (Ara) - Medi-Cal Consent Form (Arabic)

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Armenian

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

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

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

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

• DHCS 0005 (2/08) (Arm) - Reciept of Citizenship or Identity Documents (Armenian)

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

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

• DHCS 0008 (1/08) (Arm) - 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) (Arm) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Armenian)

• DHCS 0011 (6/08) (Arm) - Proof of Acceptable Citizenship or Identity Documents (Armenian)

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

• MC 176 S  (03/09) (Arm) - Medi-Cal Status Report (Armenian)

• MC 210 (10/07) (Arm) - Medi-Cal Mail-In Application (Armenian)

• MC 210 RV (05/11) (Arm) - Medi-Cal Annual Redetermination (Armenian)

• MC 219 (2/02) (Arm) - Important Information For Persons Requesting Medi-Cal (Armenian)

• MC 223 C (06/11) (Arm) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Armenian)

• MC 239 DRA-6 (2/10) (Arm) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Armenian)

• MC 264 (9/11) (Arm) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Armenian)

• MC 321 HFP (1/10) (Arm) - Healthy Families/Medi-Cal Joint Application (Armenian) (Not DHCS)

• MC 371 (6/09) (Arm) - Additional Family Members Requesting Medi-Cal (Armenian)
• MC 372 (9/09) (Arm) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Armenian)
• MC 4034 (1/08) (Arm) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Arm) - Medi-Cal Consent Form (Armenian)
• NA Back 9 (Arm) - Your Hearing Rights (Armenian)

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Chinese

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

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

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

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

• DHCS 0005 (2/08) (Chi) - Receipt of Citizenship or Identity Documents (Chinese)

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

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

• DHCS 0008 (1/08) (Chi) - 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) (Chi) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Chinese)

• DHCS 0011 (6/08) (Chi) - Proof of Acceptable Citizenship or Identity Documents (Chinese)

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

• MC 176 S (03/09) (Chi) - Medi-Cal Status Report (Chinese)
• MC 210 (10/07) (Chi) - Medi-Cal Mail-In Application (Chinese)
• MC 210 RV (05/11) (Chi) - Medi-Cal Annual Redetermination (Chinese)
• MC 210 PS (1/09) (Chi) - Property Supplement (Chinese)
• MC 219 (2/02) (Chi) - Important Information for Persons Requesting Medi-Cal (Chinese)
• MC 223 C (06/11) (Chi) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Chinese)
• MC 239 DRA-6 (2/10) (Chi) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Chinese)
• MC 264 (9/11) (Chi) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Chinese)
• MC 321 HFP (1/10) (Chi) - Healthy Families/Medi-Cal Joint Application (Chinese) (Not DHCS)
• MC 368 (6/07) (Chi) - Notice of Supplemental Form for Express Enrollment Applicants (Chinese)
• MC 371 (6/09) (Chi) - Additional Family Members Requesting Medi-Cal (Chinese)
• MC 372 (9/09) (Chi) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Chinese)
• MC 4035 (4-08) (Chi) - Medi-Cal Consent Form (Chinese)
• MC 4034 (1/08) (Chi) - Language Services Notice (Multilingual)
• NA Back 9 (Chi) - Your Hearing Rights (Chinese)

Farsi

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

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

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

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

• DHCS 0005 (2/08) (Far) - Receipt of Citizenship or Identity Documents (Farsi)

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

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

• DHCS 0008 (1/08) (Far) - 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) (Far) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Farsi)

• DHCS 0011 (6/08) (Far) - Proof of Acceptable Citizenship or Identity Documents (Farsi)

• MC 0021 (4/07) (Far) - Medi-Cal to Healthy Families Bridging Consent Form (Farsi)
• MC 176 S (03/09) (Far) - Medi-Cal Status Report (Farsi)
• MC 210 (10/07) (Far) - Medi-Cal Mail-In Application (Farsi)
• MC 210 RV (05/11) (Far) - Medi-Cal Annual Redetermination (Farsi)
• MC 219 (2/02) (Far) - Important Information for Persons Requesting Medi-Cal (Farsi)
• MC 223 C (06/11) (Far) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Farsi)
• MC 239 DRA-6 (2/10) (Far) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Farsi)
• MC 264 (9/11) (Far) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Farsi)
• MC 321 HFP (1/10) (Far) - Healthy Families/Medi-Cal Joint Application (Farsi) (Not DHCS)
• MC 371 (6/09) (Far) - Additional Family Members Requesting Medi-Cal (Farsi)
• MC 372 (9/09) (Far) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Farsi)
• MC 4034 (1/08) (Far) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Far) - Medi-Cal Consent Form (Farsi)
• NA Back 9 (Far) - Your Hearing Rights (Farsi)

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Hmong

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

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

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

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

• DHCS 0005 (2/08) (Hmo) - Receipt of Citizenship or Identity Documents (Hmong)

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

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

• DHCS 0008 (1/08) (Hmo) - 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) (Hmo) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Hmong)

• DHCS 0011 (6/08) (Hmo) - Proof of Acceptable Citizenship or Identity Documents (Hmong)

• MC 0021 (4/07) (Hmo) - Medi-Cal to Healthy Families Bridging Consent Form (Hmong)
• MC 176 S (03/09) (Hmo) - Medi-Cal Status Report (Hmong)
• MC 210 (10/07) (Hmo) - Medi-Cal Mail-In Application (Hmong)
• MC 210 PS (5/07) (Hmo) - Property Supplement (Hmong)
• MC 210 RV (05/11) (Hmo) - Medi-Cal Annual Redetermination - Hmong
• MC 219 (2/02) (Hmo) - Important Information for Persons Requesting Medi-Cal (Hmong) 
• MC 223 C (06/11) (Hmo) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Hmong)
• MC 239 DRA-6 (2/10) (Hmo) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Hmong)
• MC 264 (9/11) (Hmo) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Hmong)
• MC 321 HFP (1/10) (Hmo) - Healthy Families/Medi-Cal Joint Application (Hmong) (Not DHCS)
• MC 368 (6/07) (Hmo) - Notice of Supplemental Form for Express Enrollment Applicants (Hmong)
• MC 371 (6/09) (Hmo) - Additional Family Members Requesting Medi-Cal (Hmong)
• MC 372 (9/09) (Hmo) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Hmong) 
• MC 4034 (1/08) (Hmo) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Hmo) - Medi-Cal Consent Form (Hmong)
• NA Back 9 (Hmo) - Your Hearing Rights (Hmong)

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Khmer (Cambodian)
• DHCS 0001 (1/08) (Cam) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Cambodian)
• DHCS 0002 (1/08) (Cam) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Cambodian)
• DHCS 0003 (6/07) (Cam) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Cambodian)
• DHCS 0004 (6/07) (Cam) - Request for California Birth Record (Cambodian)
• DHCS 0005 (2/08) (Cam) - Receipt of Citizenship or Identity Documents (Cambodian)
• DHCS 0006 (8/07) (Cam) - Proof of Citizenship and Identity (Cambodian)
• DHCS 0007 (12/07) (Cam) - Acceptable Citizenship and Identity Documents (Cambodian)
• DHCS 0008 (1/08) (Cam) - 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) (Cam) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Cambodian)
• DHCS 0011 (6/08) (Cam) - Proof of Acceptable Citizenship or Identity Documents (Cambodian)
• MC 0021 (4/07) (Cam) - Medi-Cal to Healthy Families Bridging Consent Form (Cambodian)
• MC 176 S (03/09) (Cam) - Medi-Cal Status Report (Cambodian)
• MC 210 (10/07) (Khm) - Medi-Cal Mail-In Application (Khmer)
• MC 210 RV (05/11)(Cam) - Medi-Cal Annual Redetermination (Cambodian)
• MC 219 (2/02) (Khm) - Important Information for Persons Requesting Medi-Cal (Khmer)
• MC 223 C (06/11) (Cam) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Cambodian)
• MC 239 DRA-6 (2/10) (Cam) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Cambodian)
• MC 264 (9/11) (Cam) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Cambodian)
• MC 321 HFP (1/10) (Cam) - Healthy Families/Medi-Cal Joint Application (Cambodian) (Not DHCS)
• MC 371 (6/09) (Cam) - Additional Family Members Requesting Medi-Cal (Cambodian)
• MC 372 (9/09) (Cam) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Cambodian)
• MC 4034 (1/08) (Cam) - Language Serivces Notice (Multilingual)
• MC 4035 (4/08) (Cam) - Medi-Cal Consent Form (Cambodian)

Korean
• DHCS 0001 (1/08) (Kor) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Korean)
• DHCS 0002 (1/08) (Kor) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Korean)
• DHCS 0003 (6/07) (Kor) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Korean)
• DHCS 0004 (6/07) (Kor) - Request for California Birth Record (Korean)
• DHCS 0005 (2/08) (Kor) - Receipt of Citizenship or Identity Documents (Korean)
• DHCS 0006 (8/07) (Kor) - Proof of Citizenship and Identity (Korean)
• DHCS 0007 (12/07) (Kor) - Acceptable Citizenship and Identity Documents (Korean)
• DHCS 0008 (1/08) (Kor) - 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) (Kor) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Korean)
• DHCS 0011 (6/08) (Kor) - Proof of Acceptable Citizenship or Identity Documents (Korean)
• MC 0021 (4/07) (Kor) - Medi-Cal to Healthy Families Bridging Consent Form (Korean)
• MC 176 S (03/09) (Kor) - Medi-Cal Status Report (Korean)
• MC 210 (10/07) (Kor) - Medi-Cal Mail-In Application (Korean)
• MC 210 RV (05/11)(Kor) - Medi-Cal Annual Redetermination (Korean)
• MC 219 (2/02) (Kor) - Important Information for Persons Requesting Medi-Cal (Korean)
• MC 223 C (06/11) (Kor) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Korean)
• MC 239 DRA-6 (2/10) (Kor) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Korean)
• MC 264 (9/11) (Kor) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Korean)
• MC 321 HFP (1/10) (Kor) - Healthy Families/Medi-Cal Joint Application (Korean) (Not DHCS)
• MC 371 (6/09) (Kor) - Additional Family Members Requesting Medi-Cal (Korean)
• MC 372 (9/09) (Kor) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Korean)
• MC 4034 (1/08) (Kor) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Kor) - Medi-Cal Consent Form (Korean)
• NA Back 9 (Kor) - Your Hearing Rights (Korean)

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 Laotian
• DHCS 0001 (1/08) (Lao) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Laotian)
• DHCS 0002 (1/08) (Lao) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Laotian)
• DHCS 0003 (6/07) (Lao) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Laotian)
• DHCS 0004 (6/07) (Lao) - Request for California Birth Record (Laotian)
• DHCS 0005 (2/08) (Lao) - Receipt of Citizenship or Identity Documents (Laotian)
• DHCS 0006 (8/07) (Lao) - Proof of Citizenship and Identity (Laotian)
• DHCS 0007 (12/07) (Lao) - Acceptable Citizenship and Identity Documents (Laotian)
• DHCS 0008 (1/08) (Lao) - Proof of Citizenship and Identity Requirements -- For Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families/Medi-Cal Joint Application (Laotian)
• DHCS 0009 (9/07) (Lao) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Laotian)
• DHCS 0011 (6/08) (Lao) - Proof of Acceptable Citizenship or Identity Documents (Laotian)
• MC 0021 (4/07) (Lao) - Medi-Cal to Healthy Families Bridging Consent Form (Laotian)
• MC 210 (10/07) (Lao) - Medi-Cal Mail-In Application (Laotian)
• MC 219 (2/02) (Lao) - Important Information for Persons Requesting Medi-Cal (Laotian)
• NA Back 9 (Lao) - Your Hearing Rights (Laotian)

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Russian
• DHCS 0001 (1/08) (Rus) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Russian)
• DHCS 0002 (1/08) (Rus) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Russian)
• DHCS 0003 (6/07) (Rus) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Russian)
• DHCS 0004 (6/07) (Rus) - Request for California Birth Record (Russian)
• DHCS 0005 (2/08) (Rus) - Receipt of Citizenship or Identity Documents (Russian)
• DHCS 0006 (8/07) (Rus) - Proof of Citizenship and Identity (Russian)
• DHCS 0007 (12/07) (Rus) - Acceptable Citizenship and Identity Documents (Russian)
• DHCS 0008 (1/08) (Rus) - 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) (Rus) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Russian)
• DHCS 0011 (6/08) (Rus) - Proof of Acceptable Citizenship or Identity Documents (Russian)
• MC 0021 (4/07) (Rus) - Medi-Cal to Healthy Families Bridging Consent Form (Russian)
• MC 176 S (03/09) (Rus) - Medi-Cal Status Report (Russian)
• MC 210 (10/07) (Rus) - Medi-Cal Mail-In Application (Russian)
• MC 210 RV (05/11) (Rus) - Medi-Cal Annual Redetermination (Russian)
• MC 210 PS (5/07) (Rus) - Property Supplement (Russian)
• MC 219 (2/02) (Rus) - Important Information for Persons Requesting Medi-Cal (Russian)
• MC 223 C (06/11) (Rus) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Russian)
• MC 239 DRA-6 (2/10) (Rus) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Russian)
• MC 264 (9/11) (Rus) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Russian)
• MC 321 HFP (1/10) (Rus) - Healthy Families/Medi-Cal Joint Application (Russian) (Not DHCS)
• MC 368 (6/07) (Rus) - Notice of Supplemental Form for Express Enrollment Applicants (Russian) 
• MC 371 (7/09) (Rus)- Additional Family Members Requesting Medi-Cal (Russian)
• MC 372 (9/09) (Rus) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Russian)
• MC 4034 (1/08) (Rus) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Rus) - Medi-Cal Consent Form (Russian)
• NA Back 9 (Rus) - Your Hearing Rights (Russian)

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Spanish
• CW 2.1 NA (SP) (8/04) (Sp) - Notice and Agreement ofr Child, Spousal, and Medical Support (Spanish)
• CW 2.1 Q (SP) (7/01) (Sp) - Support Questionnaire (Spanish)
• CW 51 (SP) (7/01) (Sp) - Child Support - Good Cause for Noncooperatio (Spanish) 
• DHCS 0001 (7/09) (Sp) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Spanish)
• DHCS 0002 (1/08) (Sp) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals (Spanish)
• DHCS 0003 (6/07) (Sp) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Spanish)
• DHCS 0004 (6/07) (Sp) - Request for California Birth Record (Spanish)
• DHCS 0005 (2/08) (Sp) - Receipt of Citizenship or Identity Documents (Spanish)
• DHCS 0006 (8/07) (Sp) - Proof of Citizenship and Identity (Spanish)

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

• DHCS 0008 (1/08) (Sp) - 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) (Sp) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Spanish)

• DHCS 0011 (6/08) (Sp) - Proof of Acceptable Citizenship or Identity Documents (Spanish)

• DHCS 7068 (7/07) (Sp) - Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives (Spanish)
• DHCS 7077 (1/12) (Sp) - Notice Regarding Standards for Medi-Cal Eligibility (Spanish)
• DHCS 7077 A (7/07) (Sp) - Notice Regarding Transfer of a Home for Both a Married and an Unmarried Applicant/Beneficiary (Bilingual)
• DHCS 7096 (7/07) (Sp) - Department of Developmental Services Waiver Referral (Spanish)
• DHCS 7102 (1/12) (Sp) - Notice Regarding Standards for Medi-Cal Eligibility for Distribution by Insurers, Agents, and Brokers (Spanish)
• MC Information Notices (Spanish)
• MC 0021 (4/07) (Sp) - Medi-Cal to Healthy Families Bridging Consent Form (Spanish)
• MC 14 A (09/11) (Sp) - Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI) Application (Spanish) 
• County Listing (Spanish)
• MC 18 (7/07) (Sp) - Important Notice About Your Medi-Cal Benefits (Bilingual)
• MC 174 (5/07) (Sp) - Medi-Cal Notice to Providers - Clarification of Liability (Bilingual)
• MC 176 PA-A (1/09) (Sp) - Medi-Cal Property Assessment Application
• MC 176 PA-1/PA-2 (5/07) (Sp) - Property Worksheet/Assessment for Institutionalized Spouses (Bilingual)
• MC 176 S (03/09) (Sp) - Medi-Cal Status Report (Spanish)
• MC 176 TMC (10/08) (Sp) - Transitional Medi-Cal (TMC) Quarterly Status Report (Spanish)
• MC 179 (1/08) (Sp) - Disability Evaluation Form (Spanish)
• MC 210 (3/10) (Sp) - Medi-Cal Mail-In Application (Spanish)
• MC 210 A (9/07) (Sp) - Supplement to Statement of Facts for Retroactive Coverage/Restoration (Spanish)
• MC 210 B (8/01) (Sp) - Supplement to Statement of Facts (Pickle Eligibility/Determination) (Spanish)
• MC 210 PA (5/07) (Sp) - Property Assessment Statement of Facts (Spanish)
• MC 210 PS (5/07) (Sp) - Property Supplement (Spanish)
• MC 210 RV (05/11) (Sp) - Medi-Cal Annual Redetermination (Spanish)
• MC 210 S-C (5/07) (Sp) - Additional Children (Supplement to the Medi-Cal Statement of Facts, MC 210) (Bilingual)
• MC 210 S-E (5/07) (Sp) - Student Educational Expenses (Supplement to the Medi-Cal Statement of FActs, MC 210) (Spanish)
• MC 210 S-I - (9/08) (Sp) - Income In-Kind/Housing Verifications (Supplement to the Medi-Cal Statement of Facts, MC 210) (Bilingual)
• MC 210 S-W (7/07) (Sp) - Vocational and Work History (Spanish)
• MC 212 (7/07) (Sp) - Medi-Cal Residency Declaration (Bilingual)
• MC 214 (7/07) (Sp) - Important Information About Residency (Spanish)
• MC 215 (10/07) (Sp) - Request for Withdrawal and/or Waiver of Ten-Day Advance Notice (Spanish)
• MC 219 (4/10) - Important Information for Persons Requesting Medi-Cal
• MC 220 8pt (6/08) (Sp) - Authorization for Release of Information - 8 point print (Spanish)
• MC 220 14pt (4/08) (Sp) - Authorization for Release of Information - 14 point print (Spanish)
• MC 223 (5/07) (Sp) - Applicant's Supplemental Statement of Facts for Medi-Cal (Spanish)
• MC 223 C (06/11) (Sp) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Spanish)
• MC 239 Back (C) (7/07) (Sp) - Your Right to Appeal This Action (Spanish)
• MC 239 DRA-6 (2/10) (Sp) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Spanish)
• MC 250 A (05/07) (Sp) - 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) (Sp) - Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU) (Spanish)
• MC 263 S-R (2/09) (Sp) - Statement of California Residency (Spanish)
• MC 264 (9/11) (Sp) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Spanish)
• MC 265 (6/07) (Sp) - Patient Directions for Presumptive Eligibility Application (Spanish)
• MC 267 (5/08) (Sp) - Explanation of Ineligibility for Presumptive Eligibility (Spanish)
• MC 273 (5/07) (Sp) - Work Activity Report (Spanish)
• MC 274 TB (5/07) (Sp) - Medi-Cal Tuberculosis Program Application (Spanish)
• MC 306 (1/08) (Sp) - Appointment of Representative (Spanish)
• MC 321 HFP (1/10) (Sp) - Healthy Families/Medi-Cal Joint Application (Spanish) (Not DHCS)
• MC 322 (9/07) (Sp) - Real and Personal Property - Supplement to Medi-Cal Mail-In Application (Spanish)
• MC 330 (7/11) (Sp) - Newborn Referral (Not an Application for Medi-Cal) (Spanish)
• MC 338 Flyer (5/07) (Sp) - Medi-Cal Program for Workers with Disabilities 250 Percent Working Disabled Program (Spanish)
• MC 354 (5/07) (Sp) - Medi-Cal Contact Update (Spanish)
• MC 355 (6/08) (Sp) - Medi-Cal Request for Information (Spanish)
• MC 356 (5/07) (Sp) - 356-"Safe Arms for Newborns" Medical Questionnaire (Spanish)
• MC 368 A (11/10) (Sp) - Important Information for Medi-Cal Applicants (Spanish)
• MC 368 M (6/07) (Sp) - Supplemental Form for Express Enrollment Applicants (Spanish)
• MC 371 (6/09) (Sp) - Additional Family Members Requesting Medi-Cal (Spanish)
• MC 372 (9/09) (Sp) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Spanish)
• MC 4026 (7/07) (Sp) - Request for Eligibility Limited Services (Spanish)
• MC 4034 (1/08) (Sp) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Sp) - Medi-Cal Consent Form (Spanish)
• NA Back 9 (Sp) - Your Hearing Rights (Spanish)
• SAWS 2 (1/07) (Sp) - 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 Information Notice 002 (9/07) (Sp) - Summary Medi-Cal Eligibility (Spanish)(PDF, 2.18MB)
• MC Information Notice 003 (6/07) (Sp) - Early and Periodic Screening, Diagnosis, and Treatment Services (Spanish)

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

• MC Information Notice 007 (1/12) (Sp) - Medi-Cal General Property Limitations (Spanish)
• MC Information Notice 008 (10/11) (Sp) - Qualified Medicare Beneficiary Program (Spanish)
• MC Information Notice 010 (1/09) (Sp) - Qualified Disabled Working Individual (Spanish)
• MC Information Notice 013 (5/07) (Sp) - Important Information Regarding Your Appeal Rights (Spanish)
• MC Information Notice 017 (7/07) (Sp) - What You Should Know About Your Medi-Cal Disability Application (Bilingual)

 

Tagalog
• DHCS 0001 (1/08) (Tag) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Tagalog)
• DHCS 0002 (1/08) (Tag) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Tagalog)
• DHCS 0003 (6/07) (Tag) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Tagalog)
• DHCS 0004 (6/07) (Tag) - Request for California Birth Record (Tagalog)
• DHCS 0005 (2/08) (Tag) - Receipt of Citizenship or Identity Documents (Tagalog)
• DHCS 0006 (8/07) (Tag) - Proof of Citizenship and Identity (Tagalog)
• DHCS 0007 (12/07) (Tag) - Acceptable Citizenship and Identity Documents (Tagalog)
• DHCS 0008 (1/08) (Tag) - 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) (Tag) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Tagalog)
• DHCS 0011 (6/08) (Tag) - Proof of Acceptable Citizenship or Identity Documents (Tagalog)
• MC 0021 (4/07) (Tag) - Medi-Cal to Healthy Families Bridging Consent Form (Tagalog)
• MC 176 S (3/09) (Tag) - Medi-Cal Status Report (Tagalog)
• MC 210 RV (05/11) (Tag) - Medi-Cal Annual Redetermination (Tagalog)
• MC 223 C (06/11) (Tag) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Tagalog)
• MC 239 DRA-6 (2/10) (Tag) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Tagalog)
• MC 264 (9/11) (Tag) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Tagalog)
• MC 321 (1/10) (Tag) - Healthy Families/Medi-Cal Joint Application (Tagalog) (Not DHCS)
• MC 371 (6/09) (Tag) - Additional Family Members Requesting Medi-Cal (Tagalog)
• MC 372 (9/09) (Tag) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Tagalog)
• MC 4034 (1/08) (Tag) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Tag) - Medi-Cal Consent Form

Vietnamese

• DHCS 0001 (1/08) (Vie) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (Vietnamese)
• DHCS 0002 (1/08) (Vie) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals (Vietnamese)
• DHCS 0003 (6/07) (Vie) - Affidavit of Reasonable Effort to Get Proof of Citizenship (Vietnamese)
• DHCS 0004 (6/07) (Vie) - Request for California Birth Record (Vietnamese)
• DHCS 0005 (2/08) (Vie) - Receipt of Citizenship or Identity Documents (Vietnamese)
• DHCS 0006 (8/07) (Vie) - Proof of Citizenship and Identity (Vietnamese)
• DHCS 0007 (12/07) (Vie) - Acceptable Citizenship and Identity Documents (Vietnamese)
• DHCS 0008 (1/08) (Vie) - 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) (Vie) - Affidavit of Identity for U.S. Citizen or National Children Under 18 (Vietnamese)
• DHCS 0011 (6/08) (Vie) - Proof of Citizenship or Identity Documents (Vietnamese)
• MC 0021 (4/07) (Vie) - Medi-Cal to Healthy Families Bridging Consent Form (Vietnamese)
• MC 176 S (03/09) (Vie) - Medi-Cal Status Report (Vietnamese)
• MC 210 (10/07) (Vie) - Medi-Cal Mail-In Application (Vietnamese)
• MC 210 RV (05/11) (Vie) - Medi-Cal Annual Redetermination (Vietnamese)
• MC 219 (2/02) (Vie) - Important Information for Persons Requesting Medi-Cal (Vietnamese)
• MC 223 C (06/11) (Vie) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18 (MC 223 C) Instructions (Vietnamese)
• MC 239 DRA-6 (2/10) (Vie) - Information Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration (Vietnamese)
• MC 264 (9/11) (Vie) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet (Vietnamese)
• MC 321 HFP (1/10) (Vie) - Healthy Families/Medi-Cal Joint Application (Vietnamese) (Not DHCS)
• MC 371 (6/09) (Vie) - Additional Family Members Requesting Medi-Cal (Vietnamese)
• MC 372 (9/09) (Vie) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer (Vietnamese)
• MC 4034 (1/08) (Vie) - Language Services Notice (Multilingual)
• MC 4035 (4/08) (Vie) - Medi-Cal Consent Form (Vietnamese)
• NA Back 9 (Vie) - Your Hearing Rights (Vietnamese)