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Medi-Cal Eligibility Divison forms are listed alphabetically below by form number and may include alternate languages if available. PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing.
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On February 8, 2005, President Bush signed into law the DRA which made certain changes to Medicaid (Medi-Cal in California) law. One of those changes was the requirement for individuals declaring to be U.S. citizens or U.S. nationals to show documentary evidence of this fact as well as proof of identity. This website contains information on both the state and federal law regarding this requirement and the implementation of this requirement in California.
DHCS 0001 (05/09) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0002 (01/08) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0003 (06/07) - Affidavit of Reasonable Effort to Get Proof of Citizenship Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0004 (06/07) - Request for California Birth Record Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0005 (02/08) - Receipt of Citizenship and Identity Documents Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0006 (08/07) - Proof of Citizenship and Identity Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0007 (12/07) - Acceptable Citizenship and Identity Documents Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0008 (01/08) - Proof of Citizenship and Identity Requirements - For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0009 (09/07) - Affidavit of Identity for U.S. Citizen or National Children Under 18 Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
DHCS 0011 (06/08) - Proof of Acceptable Citizenship or Identity Documents Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Laotian, Russian, Spanish, Tagalog, Vietnamese
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