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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.
NOTE: Some links on this page are documents in Adobe Acrobat Portable Document Format (PDF); unless indicated are smaller than 2 MB. PDF documents require Adobe Reader. If you need to install or upgrade to the latest version, click the “Download Free Readers”.
MC 368 (06/07) (Chi) - Notice of Supplemental Form for Express Enrollment Applicants (Chinese)MC 368 (06/07) (Hmo) - Notice of Supplemental Form for Express Enrollment Applicants (Hmong)MC 368 (06/07) (Rus) - Notice of Supplemental Form for Express Enrollment Applicants (Russian)
MC 373 (09/09) - County Referral to the Breast and Cervical Cancer Treatment Program
MC 380 (06/18) - Notice of Authorized Representative Appointment
MC 381 (06/18) - Authorized Representative Cancellation Letter
MC 382 (06/18) - Appointment of Authorized Representative Form
MC 383 (06/18) - Authorized Representative Standard Agreement
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