MCEB Forms by Number

Medi-Cal Eligibility Forms Listed by Number

Medi-Cal Eligibility forms are listed alphabetically below by form number. PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing.

Notice of Action (NOA) forms are available through a secured website on the MEDS homepage. This is a confidentially secured website and you will need your password to access this page.

Medi-Cal Eligibility Forms translated into 12 languages

CW 2.1 NA (8/04) (Not DHCS) - Notice and Agreement for Child, Spousal and Medical Support

CW 2.1 Q (7/01) (Not DHCS) - Support Questionnaire

CW 51 (12/10) (Not DHCS) - Child Support - Good Cause Claim for Noncooperation

DHCS 0001 (5/09) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity

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

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

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

DHCS 0005 (2/08) - Receipt of Citizenship and Identity Documents

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

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

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

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

DHCS 0010 (1/08) - Affidavit of Identity for U.S. Citizens or National for Disabled Individuals Living in Institutional Care Facilities

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

DHCS 6168 (2/11) - Potential Third Party Liability Notification

DHCS 7013 (6/07)(PDF, 2.79MB)) - Change of Status-Liens

DHCS 7014 (6/07) - Property Lien Referral

DHCS 7019 (5/07) - Pickle Eligibles Financial Eligibility Work Sheet—Eligible Child With Ineligible Parent or Parents

DHCS 7020 (6/07) - Screening Work Sheet

DHCS 7021 (5/07) - Financial Eligibility Work Sheet (Individual or Couple, Applicant With an Ineligible Spouse) Instructions

DHCS 7029 (6/07) - Disregard Computation Work Sheet (Pickle Eligible Individual or Couple and/or Ineligible Spouse with RSDI Income)

DHCS 7035 A (6/07) - Medical Report on Adult with Allegation of Human Immunodeficiency Virus (HIV) Infection

DHCS 7035 C (4/08) - Medical Report on Child with Allegation of Human Immunodeficiency Virus (HIV) Infection

DHCS 7037 (5/07) - Pickle Resource Work Sheet

DHCS 7044 (12/08) - Statement of Living Arrangements, In-Kind Support, and Maintenance

DHCS 7045 (5/07) - Worker Observations—Disability

DHCS 7068 (6/07) - Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives

DHCS 7071 (6/07) - Medi-Cal Waiver Information and Authorization

DHCS 7075 (5/07) - Pickle Needs Test

DHCS 7077 (1/12) - Notice Regarding Standards for Medi-Cal Eligibility
More Info**

DHCS 7077 A (5/07) - Notice Regarding Transfer of a Home for both a Married and an Unmarried Applicant/Beneficiary (Eng/Sp)

DHCS 7089 (5/07) - Screening Worksheet Disabled Widow(er) Checklist (DW) Ages 50 to 64

DHCS 7096 (5/07) - Department of Developmental Services Waiver Referral

DHCS 7102 (1/12) - Notice Regarding Standards for Medi-Cal Eligibility for Distribution by Insurers, Agents, and Brokers

MC Information Notice 002 (9/07) - Summary Medi-Cal Eligibility

MC Information Notice 003 (6/07) - Early and Periodic Screening, Diagnosis and Treatment Services

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

MC Information Notice 007 (1/12) - Medi-Cal General Property Limitations

MC Information Notice 008 (10/11) - Qualified Medicare Beneficiary Program Information Notice

MC Information Notice 010 (5/07) - Qualified Disabled Working Individual Information Notice

MC Information Notice 013 (5/07) - Important Information Regarding Your Appeal Rights

MC 13 (12/09) - Statement of Citizenship, Alienage, and Immigration Status

MC 14 A (09/11) - Qualified Low-Income Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Qualifying Individuals (QI) Application
County Listing

MC 017 Information Notice (6/07) - What you Should Know About Your Medi-Cal Disability Application (Eng/Sp)

MC 18 (BI) (6/07) - Important Notice About Your Medi-Cal Benefits

MC 19 (8/07) - Important Information for New Supplemental Security Income/State Supplementary Payment (SSI/SSP) Recipients

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

MC 0025 (3/10) - Transmittal to CDCR Public Benefit Specialist on Determination of a Ward's/Inmate's Medi-Cal Eligibility

MC 0026 (8/11) - Medi-Cal Order form

MC 0027 (3/10) - Referral Form for the Assisted Living (AL) Waiver

MC 61 (5/07) - Medical Report

MC 171 (5/07) - Medi-Cal Long-Term Care Facility Admission and Discharge Notification

MC 174 (5/07) - Medi-Cal Notice to Providers Clarification of Liability (Eng/Sp)

MC 175 I (5/07) - Sneede v. Kizer Income Screening Questions

MC 175-2 (5/07) - Sneede v. Kizer Responsible Relative Determination

MC 175-3I (5/07) - Sneede v. Kizer Net Nonexempt Income Determination

MC 175-3I.1 (5/07) - Sneede v. Kizer Net Nonexempt Income Determination-Continuation Sheet

MC 175-3I.2A (5/07) - Section 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Determination - Applicant

MC 175-3I.2R (5/07) - Section 1931(b) Sneede v. Kizer Net Nonexempt Income Determination and Mini Budget Unit (MBU) Determination - Recipient

MC 175-P (5/07) - Sneede v. Kizer Property Screening Questions

MC 175-3P (5/07) - Sneede v. Kizer Property Work Sheet

MC 175-4 (5/07) - Sneede v. Kizer Mini Budget Units And:

MC 175-5 (5/07) - Federal Poverty Level (FPL) Programs for Pregnant Women and Infants (Income Disregard, 200 Percent); Children Ages 1 through 5 (133 Percent); and Children Ages 6 through 18 (100 Percent) (For County Use Only)

MC 175-6 (5/07) - Sneede v. Kizer Allocation from an SSI or IHSS Person

MC 175-7 (5/07) - Sneede v. Kizer Allocation Work Sheet Board and Care Person to Spouse and/or Children at Home or LTC Person (AFDC/MN/MI) With No Community Spouse to Children at Home

MC 176-1 QMB/SLMB/QI (5/07) - Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Eligibility Work Sheet For All Applicants: Individual(s), Couple(s), and Child(ren) (LTC Individual in MFBU)

MC 176-2A QMB/SLMB/QI (5/07) - Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Income Eligibility Work Sheet, Couple or Applicant with an Ineligilbe Spouse, With or Without Child(ren)

MC 176-2B QMB/SLMB/QI (5/07) - Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Income Eligibility Work Sheet, Child Applying with or without Ineligible Parent(s)

MC 176 AD (5/07) - Aged and Disabled Federal Poverty Level Program Financial Eligibility Form

MC 176 D (5/07) - Medi-Cal Special Treatment Programs

MC 176 EP (5/07) - Exempt Payment Form

MC 176 M (5/07) - Share of Cost Determination - MFBUs Which Do Not Include LTC Persons

MC 176 M-LTC (11/07) - Share of Cost Determination - MFBUs with LTC Persons Included - LTC

MC 176 P (5/07) - Property Reserve Worksheet

MC 176 PA-1/PA-2 (5/07) - Property Worksheet/Assessment for Institutionalized Spouses (Eng/Sp)

MC 176 P-A QMB/SLMB/QI (9/08) - Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Property Work Sheet, Adult

MC 176 PA-A (5/07) - Medi-Cal Property Assessment Application

MC 176 P-C QMB/SLMB/QI (5/07) - Qualified Medicare Beneficiary (QMB)/Specified Low-Income Medicare Beneficiary (SLMB)/Qualifying Individual (QI) Property Work Sheet, Child

MC 176 PI (5/07) - Period of Ineligibility for Nursing Facility Level-of-Care Work Sheet

MC 176 PV (5/07) - Vehicle Determination Worksheet for 1931 Group

MC 176 QMB-3 (5/07) - Qualified Medicare Beneficiary (QMB) Referral

MC 176 QDWI (5/07) - Qualified Disabled Working Individual (QDWI) Income Eligibility Work Sheet-Instructions

MC 176 QDWI-2 (5/07) - Qualified Disabled Working Individual (QDWI) Property Work Sheet

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

MC 176 TMC (5/07) - Transitional Medi-Cal (TMC) Quarterly Status Report

MC 176 W (5/08) - Allocation/Special Deduction Worksheet

MC 176 W.1 (5/07) - Stepparent Computation

MC 179 (11/07) - Disability Determionation Service Division

MC 194 (5/07) - Social Security Administration Referral Notice

MC 210 (02/10) - Medi-Cal Mail-In Application

MC 210 A (9/07) - Supplement to Statement of Facts for Retroactive Coverage/Restoration

MC 210 B (5/07) - Supplement to Statement of Facts (Pickle Eligibility/ Determination)

MC 210 PA (5/07) - Property Assessment Statement of Facts

MC 210 PS (5/07) - Property Supplement

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

MC 210 RV Notice (5/07) - Medi-Cal Annual Redetermination Notice

MC 210 S-E (5/07) - Student Educational Expenses (Supplement to the Medi-Cal Statement of Facts, MC 210)

MC 210 S-I (9/08) - Income In-Kind/Housing Verification (Eng/Sp) (Supplement to the MC 210 Statement of Facts)

MC 210 S-W (5/07) - Vocational and Work History

MC 212 (5/07) - Medi-Cal Residency Declaration (Eng/Sp)

MC 214 (5/07) - Important Information About Residency

MC 215 (5/07) - Request for Withdrawal and/or Waiver of Ten-Day Advance Notice

MC 219 (4/10) - Important Information for Persons Requesting Medi-Cal

MC 220 8pt (6/08) - Authorization for Release of Information

MC 220 14pt (4/08) - Authorization for Release of Information (Large Print)

MC 221 LA (6/07) - Disability Determination and Transmittal (Los Angeles)

MC 221 OAK (6/07) - Disability Determination and Transmittal (Oakland)

MC 222 LA (8/07) - DAPD Pending Information Update (Los Angeles)

MC 222 OAK (8/07) - DAPD Pending Information Update (Oakland)

MC 223 (5/07) - Applicant's Supplemental Statement of Facts for Medi-Cal

MC 223 C (6/11) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only- Under Age 18 (MC 223C) Instructions

MC 224 A (6/07) - Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage

MC 224 A-S (5/07) - Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage

MC 224 B (6/07) - Medi-Cal Potential Overpayment Reporting Work Sheet - Property Total Ineligibility or Ineligibility For A Specific Level of Services

MC 224 B-S (5/07) - Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet - Property Total Ineligibility or Ineligibility For A Specific Level of Services

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

MC 250 (5/07) - Application and Statement of Facts for Child Not Living with a Parent or Relative and for Whom a Public Agency is Assuming Some Financial Responsibility

MC 250 A (5/07) - Application and Statement of Facts for an Individual Who is Over 18 and Under 21and Who was in Foster Care Placement on His or Her 18th Birthday

MC 262 (6/07) - Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)

MC 263 S-R (9/11) - Statement of California Residency

MC 264 (9/11) - Presumptive Eligibility Patient Fact Sheet

MC 265 (9/11) - Patient Directions for Presumptive Eligibility Application

MC 266 (9/11) - Directions to Apply for Medi-Cal

MC 267 (9/11) - Explanation for Inelgibility for Presumptive Eligibility

MC 272 (5/07) - SGA Work Sheet

MC 273 (5/07) - Work Activity Report

MC 274 TB (5/07) - Medi-Cal Tuberculosis Program Application

MC 278 TB (5/07) - Tuberculosis (TB) Program Property Worksheet Adult

MC 279 TB (5/07) - Tuberculosis (TB) Program Property Worksheet Child

MC 280 TB (5/07) - Tuberculosis (TB) Program Financial Eligibility Worksheet - Eligible Child with Ineligible Parent or Parent(s)

MC 281 TB (5/07) - Tuberculosis (TB) Program Income Eligibility Worksheet

MC 282 (TB) (5/07) - Tuberculosis (TB) Program Income Eligibility Worksheet

MC 283 (9/11) - Weekly Presumptive Eligibility (PE) Enrollment Summary

MC 285 (02/12) - Forms Order - Presumptive Eligibility (PE)

MC 286 (9/11) - Presumptive Eligibility Provider Fact Sheet

MC 306 (6/07) - Appointment of Representative

MC 311 (10/07) - Qualified Provider Application for Presumptive Eligibility Participation

MC 321 HFP (7/10) (Not DHCS)- Healthy Families/Medi-Cal Joint Application

MC 322 (5/07) - Real and Personal Property - Supplement to Medi-Cal Mail-in Application

MC 324 (5/07) - Sneede v. Kizer Section 1931(b) Property Work Sheet

MC 325 (5/07) - Request for Transitional Medi-Cal (TMC) or Four Month Continuing Medi-Cal

MC 326 A (5/07) - Supplemental Security Income (SSI) Methodology Adult Income Eligibility Worksheet

MC 326 C (5/07) - Supplemental Security Income (SSI) Methodology Income Worksheet - Eligible Child with Ineligible Parent or Parent(s)

MC 327 A (5/07) - Supplemental Security Income (SSI) Program Property Worksheet Adult

MC 327 C (5/07) - Supplemental Security Income (SSI) Program Property Worksheet Child

MC 330 (7/11) - Newborn Referral (Not an Application for Medi-Cal-(fillable)

MC 337 (5/07) - 100 Hours or More Unemployed Parent Determination Work Sheet

MC 338 (5/07) - 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program - Adults

MC 338 Instructions (5/07) - Instructions 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program - Adults

MC 338 A (5/07) - SSI/SSP Income Test Work sheet For The 250 Percent Working Disabled Program - Adults

MC 338 B (5/07) - 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program - Child Applying with or without Ineligible Parent(s)

MC 338 C (5/07) - SSI/SSP Property Test Worksheet For The 250 Percent Working Disabled Program - Adults and Child Applicants

MC 338 Flyer (5/07) - New Medi-Cal Program for Workers with Disabilities: 250 Percent Working Disabled Program

MC 338 G (6/07) - 250 Percent Working Disabled Program Premium Payment Information

MC 338 J (5/07) - Premium Differential Work Sheet in the 250 Percent Working Disabled Program

MC 354 (5/07) - Medi-Cal Contact Update

MC 355 (5/07) - Medi-Cal Request for Information

MC 356 (5/07) - "Safe Arms for Newborns" Medical Questionnaire

MC 360 (6/07) - Notification of Medi-Cal Intercounty Transfer

MC 360 R (5/07) - Medi-Cal Intercounty Transfer Packet Receipt

MC 363 (5/07) - Medi-Cal to Healthy Families Transmittal

MC 363 S (5/07) - County Summary Transmittal

MC 364 (5/07) - California Department of Aging (CDA) Waiver Referral

MC 368 A (11/10) - Important Information for Medi-Cal Applicants

MC 368 M (6/07) - Express Enrollment Supplemental Form for Medi-Cal, Healthy Families and Healthy Kids

MC 370 (11/11) - Healthy Families/Medi-Cal Application Order Form

MC 371 (7/09) - Additional Family Members Requesting Medi-Cal

MC 372 (9/09) - Breast and Cervical Cancer Treatment Program (BCCTP)

MC 373 (9/09) - County Referral to the Breast and Cervical Cancer Treatment Program

MC 1054 (6/07) - Share-of-Cost Medi-Cal Provider Letter

MC 4026 (5/07) - Request for Eligibility Limited Services

MC 4033 (6/07) - Disability Listing Update

MC 4034 (1/08) - Language Services Notice

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

NA Back 9 (Not DHCS) - Your Hearing Rights

PUB 68 (11/10) - Medi-Cal What it Means to You, PUB 68 (English/Spanish)

SAWS 1 (12/06) (Not DHCS) - Coversheet to the Application for Cash Aid, Food Stamps and/or Medi-Cal/34-County Medical Services Program (CMSP)

SAWS 2 (7/07) (Not DHCS) - Statement of Facts for Cash Aid, Food Stamps, and Medi-Cal- State-Run County Medical Services Program (CMSP)