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Medi-Cal Members:
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. Log on to
your account
or contact
your county office
to update your information.
Important
Are you enrolled in Medi-Cal? Has your contact information changed in the past two years? Give your local county office your updated contact information so you can stay enrolled.
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Forms By Name - E
Established CCS/GHPP Client Service Authorization Request (SAR)
(DHCS 4509, 11/07)
Exempt Payment Form
(MC 176 EP, 05/07)
Explanation for Ineligibility for Presumptive Eligibility (MC 267, 09/11)
Alt:
Spanish
(05/08)
Express Enrollment Supplemental Form for Medi-Cal, Healthy Families and Healthy Kids
(MC 368 M, 06/07)
Alt:
Spanish
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Last modified date: 8/22/2025 9:36 AM
