Home Forms, Laws, and Publications Forms Medi-Cal Eligibility Division Translated Forms: Farsi

Medi-Cal Eligibility Division Translated Forms: Farsi

Medi-Cal Eligibility Division (MCED) forms are listed below, alphabetically, by form number and has been translated into Farsi.

يمكن تعبئة نماذج PDF وطباعتها عبر الإنترنت وطباعتها على نسخة ورقية لتوقيعها وإرسالها بالبريد أو تقديمها شخصيًا إلى موظف مختص بالأهلية للمعالجة.

نماذج DHCS: الفارسية

DHCS 0001 (01/08) (Far) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity
DHCS 0002 (01/08) (Far) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals
DHCS 0005 (02/08) (Far) – Receipt of Citizenship or Identity Documents
DHCS 0007 (12/07) (Far) – Acceptable Citizenship and Identity Documents
DHCS 0008 (01/08) (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
DHCS 0004 (06/07) (Far) – Request for California Birth Record
DHCS 0005 (02/08) (Far) – Receipt of Citizenship or Identity Documents
DHCS 0006 (08/07) (Far) – Proof of Citizenship and Identity
DHCS 0007 (12/07) (Far) – Acceptable Citizenship and Identity Documents
DHCS 0008 (01/08) (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
DHCS 0009 (09/07) (Far) – Affidavit of Identity for U.S. Citizen or National Children Under 18
DHCS 0011 (06/08) (Far) – Proof of Acceptable Citizenship or Identity Documents
MC 0021 (04/07) (Far) – Medi-Cal to Healthy Families Bridging Consent Form

MC 176 S (03/09) (Far) – Medi-Cal Status Report
MC 209 (05/12) (Far) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
MC 210 RV (05/11) (Far) – Medi-Cal Annual Redetermination
MC 219 (11/15) (Far) – Important Information for Persons Requesting Medi-Cal
MC 223 C (06/11) (Far) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only – Under Age 18
MC 223 (10/09) (Far) – Applicant’s supplemental statement of facts for Medi-Cal Adult Applicant Only
MC 239 DRA-6 (02/10) (Far) – Info Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
MC 264 (09/11) (Far) – Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet
MC 371 (06/09) (Far) – Additional Family Members Requesting Medi-Cal
MC 372 (12/21) (Far) – Breast and Cervical Cancer Treatment Program (BCCTP) Flyer
MC 4035 (04/08) (Far) – Medi-Cal Consent Form

MC Information Notice 003 (05/13) (Far) – Early and Periodic Screening, Diagnosis, and Treatment Services