Medi-Cal Eligibility Division Translated Forms: Spanish
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Medi-Cal Eligibility Division forms are listed below, alphabetically, by form number and has been translated into Spanish
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Formularios DHCS: Español
- DHCS 0001 (07/09) (Sp) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity
- DHCS 0002 (01/08) (Sp) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals
- DHCS 0005 (02/08) (Sp) – Receipt of Citizenship or Identity Documents
- DHCS 0007 (12/07) (Sp) – Acceptable Citizenship and Identity Documents
- DHCS 0008 (01/08) (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
- DHCS 0009 (09/07) (Sp) – Affidavit of Identity for U.S. Citizen or National Children Under 18
- DHCS 0011 (06/08) (Sp) – Proof of Acceptable Citizenship or Identity Documents
- DHCS 7068 (07/07) (Sp) – Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives
- DHCS 7077 (01/25) (Sp) – Notice Regarding Standards for Medi-Cal Eligibility
- DHCS 7077 A (07/07) (Eng/Sp) – Notice Regarding Transfer of a Home for Both a Married and an Unmarried Applicant/Beneficiary
- DHCS 7096 (07/07) (Sp) – Department of Developmental Services Waiver Referral
- DHCS 7102 (05/24) (Sp) – Notice Regarding Standards for Medi-Cal Eligibility for Distribution by Insurers, Agents, and Brokers
Formularios MC: Español
- MC 0021 (04/07) (Sp) – Medi-Cal to Healthy Families Bridging Consent Form
- MC 14 A (09/11) (Sp) – Qualified Low-Income Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individuals Application
- Listado de Condado (Sp)
- MC 18 (07/07) (Eng/Sp) – Important Notice About Your Medi-Cal Benefits
- MC 174 (05/07) (Eng/Sp) – Medi-Cal Notice to Providers – Clarification of Liability
- MC 176 PA-A (01/09) (Sp) – Medi-Cal Property Assessment Application
- MC 176 PA-1/PA-2 (05/07) (Sp) – Property Worksheet/Assessment for Institutionalized Spouses
- MC 176 S (03/09) (Sp) – Medi-Cal Status Report
- MC 176 TMC (10/08) (Sp) – Transitional Medi-Cal (TMC) Quarterly Status Report
- MC 179 (01/08) (Sp) – Disability Evaluation Form
- MC 209 (05/12) (Sp) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
- MC 210 A (09/07) (Sp) – Supplement to Statement of Facts for Retroactive Coverage/Restoration
- MC 210 B (08/01) (Sp) – Supplement to Statement of Facts
- MC 210 PA (05/07) (Sp) – Property Assessment Statement of Facts
- MC 210 PS (05/07) (Sp) – Property Supplement
- MC 210 RV (05/11) (Sp) – Medi-Cal Annual Redetermination
- MC 210 S-C (05/07) (Sp) – Additional Children
- MC 210 S-E (05/07) (Sp) – Student Educational Expenses
- MC 210 S-I – (09/08) (Sp) – Income In-Kind/Housing Verifications
- MC 210 S-W (07/07) (Sp) – Vocational and Work History
- MC 212 (07/07) (Sp) – Medi-Cal Residency Declaration
- MC 214 (07/07) (Sp) – Important Information About Residency
- MC 215 (10/07) (Sp) – Request for Withdrawal and/or Waiver of Ten-Day Advance Notice
- MC 219 (11/15) (Sp) – Important Information for Persons Requesting Medi-Cal
- MC 220 8pt (06/08) (Sp) – Authorization for Release of Information – 8 point print
- MC 220 14pt (04/08) (Sp) – Authorization for Release of Information – 14 point print
- MC 223 C (06/11) (Sp) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only – Under Age 18
- MC 223 (10/09) (Sp) – Applicant’s supplemental statement of facts for Medi-Cal Adult Applicant Only
- MC 239 DRA-6 (02/10) (Sp) – Info Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
- MC 250 A (12/14) (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
- MC 262 (06/07) (Sp) – Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
- MC 263 S-R (02/09) (Sp) – Statement of California Residency
- MC 264 (09/11) (Sp) – Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet
- MC 265 (06/07) (Sp) – Patient Directions for Presumptive Eligibility Application
- MC 267 (05/08) (Sp) – Explanation of Ineligibility for Presumptive Eligibility
- MC 273 (05/07) (Sp) – Work Activity Report
- MC 274 TB (05/07) (Sp) – Medi-Cal Tuberculosis Program Application
- MC 306 (01/08) (Sp) – Appointment of Representative
- MC 322 (09/07) (Sp) – Real and Personal Property – Supplement to Medi-Cal Mail-In Application
- MC 330 (10/24) (Sp) – Newborn Referral (Not an Application for Medi-Cal)
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MC 338 Flyer (05/07) (Sp) – Medi-Cal Program for Workers with Disabilities 250 Percent Working Disabled Program - MC 354 (05/07) (Sp) – Medi-Cal Contact Update
- MC 355 (06/08) (Sp) – Medi-Cal Request for Information
- MC 356 (05/07) (Sp) – “Safe Arms for Newborns” Medical Questionnaire
- MC 368 A (11/10) (Sp) – Important Information for Medi-Cal Applicants
- MC 368 M (06/07) (Sp) – Supplemental Form for Express Enrollment Applicants
- MC 371 (06/09) (Sp) – Additional Family Members Requesting Medi-Cal
- MC 372 (12/21) (Sp) – Breast and Cervical Cancer Treatment Program (BCCTP) Flyer
- MC 4026 (07/07) (Sp) – Request for Eligibility Limited Services
- MC 4035 (04/08) (Sp) – Medi-Cal Consent Form
Avisos Informativos MC: Español
- MC Information Notice 002 (09/07) (Sp) – Summary Medi-Cal Eligibility (2.18MB)
- MC Information Notice 003 (11/12) (Sp) – Early and Periodic Screening, Diagnosis, and Treatment Services
- MC Information Notice 004 (05/07) (Sp) – Important Information for Medi-Cal Nursing Home Patients
- MC Information Notice 007 (11/22) (Sp) – Medi-Cal General Property Limitations
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MC Information Notice 008 (10/11) (Sp) – Qualified Medicare Beneficiary Program -
MC Information Notice 010 (01/09) (Sp) – Qualified Disabled Working Individual - MC Information Notice 013 (05/07) (Sp) – Important Information Regarding Your Appeal Rights
- MC Information Notice 017 (07/07) (Sp) – What You Should Know About Your Medi-Cal Disability Application