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MC 209 (05/12) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Spanish, Tagalog, Vietnamese
MC 210 A (09/07) – Supplement to Statement of Facts for Retroactive Coverage/Restoration
Alt: Spanish
MC 210 B (05/07) – Supplement to Statement of Facts (Pickle Eligibility/ Determination)
Alt: Spanish
MC 210 PA (05/07) – Property Assessment Statement of Facts
Alt: Spanish
MC 210 RV (10/20) – Medi-Cal Annual Redetermination (English)
Alt: Arabic, Armenian, Cambodian, Chinese,  Farsi, Hindi, Hmong, Japanese, Korean,  Laotian, Mien,  Punjabi, Russian, Spanish, Tagalog, Thai, Ukrainian, Vietnamese
MC 210 S-C (05/07) – Additional Children (Supplement to the Medi-Cal Statement of Facts, MC 210) (Eng/Sp)
MC 210 S-E (05/07) – Student Educational Expenses (Supplement to the Medi-Cal Statement of Facts, MC 210)
Alt: Spanish
MC 210 S-I (09/08) – Income In-Kind/Housing Verification (Supplement to the MC 210 Statement of Facts) (Eng/Sp)
MC 210 S-W (05/07) – Vocational and Work History
Alt: Spanish
MC 212 (05/07) – Medi-Cal Residency Declaration (Eng/Sp)
MC 214 (05/07) – Important Information About Residency
Alt: Spanish
MC 215 (05/07) – Request for Withdrawal and/or Waiver of Ten-Day Advance Notice
Alt: Spanish (10/07)
MC 216 (10/20) – Pre-Populated Renewal Form
Alt: Arabic, Armenian, Cambodian, Chinese,  Farsi, Hindi,  Hmong, Japanese, Korean,  Laotian, Mien,  Punjabi, Russian,  Spanish, Tagalog, Thai, Ukrainian,  Vietnamese
MC 217 (10/20) – Pre-Populated Renewal Form
 Alt: Arabic, Armenian, Cambodian, Chinese, Farsi, Hindi, Hmong, Japanese, Korean, Laotian, Mien, Punjabi, Russian, Spanish, Tagalog, Thai, Ukrainian, Vietnamese
MC 219 (11/15) – Important Information for Persons Requesting Medi-Cal (Large Print, Eng)
    Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese
MC 220 8pt (06/08) – Authorization for Release of Information Alt: Spanish
MC 220 14pt (04/08) – Authorization for Release of Information (Large Print) Alt: Spanish
MC 221 LA (02/14) – Disability Determination and Transmittal (Los Angeles)
MC 222 LA (02/14) – DDSD Pending Information Update (Los Angeles)
MC 223 (10/09) – Applicant’s Supplemental Statement of Facts for Medi-Cal
Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese
MC 223 C (06/11) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only- Under Age 18 (MC 223C) Instructions
Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese
MC 224 A (06/07) – Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage
MC 224 A-S (05/07) – Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage
MC 224 B (06/07) – Medi-Cal Potential Overpayment Reporting Work Sheet – Property Total Ineligibility or Ineligibility For A Specific Level of Services
MC 224 B-S (05/07) – Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet – Property Total Ineligibility or Ineligibility For A Specific level of Services
MC 239 DRA-6 (02/10) – Information Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese
MC 250 (05/07) – 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 (12/14) – Application and Statement of Facts for an Individual Who is Over 18 and Under 26 and Who was in Foster Care Placement on His or Her 18th Birthday
Alt: Spanish
MC 262 (06/07) – Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
Alt: Spanish
MC 272 (05/07) – SGA Work Sheet
MC 273 (05/07) – Work Activity Report
Alt: Spanish
MC 274 TB (08/25) – Medi-Cal Tuberculosis Program Application
Alt: Spanish
MC 278 TB (05/07) – Tuberculosis (TB) Program Property Worksheet Adult
MC 279 TB (05/07) – Tuberculosis (TB) Program Property Worksheet Child
MC 280 TB (05/07) – Tuberculosis (TB) Program Financial Eligibility Worksheet – Eligible Child with Ineligible Parent or Parent(s)
MC 281 TB (05/07) – Tuberculosis (TB) Program Income Eligibility Worksheet
MC 282 TB (05/07) – Tuberculosis (TB) Program Income Eligibility Worksheet