​​​​​Forms: MC 200

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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​