​​​Medi-Cal Eligibility Division MC 300 Forms

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Medi-Cal Eligibility Division 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”. 

Update!

All Presumptive Eligibility forms for Pregnant Women will now be made available on our provider website for the following form(s):

MC 300 Forms:

MC 306 (11/15) - Appointment of Representative
    Alt: Spanish (01/08) 
MC 322 (05/07) - Real and Personal Property - Supplement to Medi-Cal Mail-in Application
    Alt: Spanish (09/07) 
MC 324 (05/07) - Sneede v. Kizer Section 1931(b) Property Work Sheet 
MC 325 (05/07) - Request for Transitional Medi-Cal (TMC) or Four Month Continuing Medi-Cal 
MC 326 A (05/07) - Supplemental Security Income (SSI) Methodology Adult Income Eligibility Worksheet 
MC 326 C (05/07) - Supplemental Security Income (SSI) Methodology Income Worksheet - Eligible Child with Ineligible Parent or Parent(s) 
MC 327 A (05/07) - Supplemental Security Income (SSI) Program Property Worksheet Adult 
MC 327 C (05/07) - Supplemental Security Income (SSI) Program Property Worksheet Child 
MC 330 (01/15) - Newborn Referral (Not an Application for Medi-Cal (fillab​le)
    Alt: Spanish
MC 337 (05/07) - 100 Hours or More Unemployed Parent Determination Work Sheet 
MC 338 (05/07) - 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program - Adults
    Alt: Instructions 
MC 338 A (05/07) - SSI/SSP Income Test Work sheet For The 250 Percent Working Disabled Program - Adults 
MC 338 B (05/07) - 250 Percent Income Test Work Sheet for the 250 Percent Working Disabled Program-Child Applying with or without Ineligible Parent(s) 
MC 338 C (05/07) - SSI/SSP Property Test Worksheet For The 250 Percent Working Disabled Program - Adults and Child Applicants 
MC 338 Flyer (05/07) - New Medi-Cal Program for Workers with Disabilities: 250 Percent Working Disabled Program
    Alt: Spanish 
MC 338 J (05/07) - Premium Differential Work Sheet in the 250 Percent Working Disabled Program 
MC 350 (05/07) - Medi-Cal Notice of Action - Approval For The Medically Needy or Medically Indigent Program Benefits
MC 354 (05/07) - Medi-Cal Contact Update
    Alt: Spanish 
MC 355 (07/18) - Medi-Cal Request for Information
    Alt: Spanish (07/18)
MC 356 (05/07) - "Safe Arms for Newborns" Medical Questionnaire
    Alt: Spanish  
MC 360 (06/07) - Notification of Medi-Cal Intercounty Transfer 
MC 360 R (05/07) - Medi-Cal Intercounty Transfer Packet Receipt 
MC 363 (05/07) - Medi-Cal to Healthy Families Transmittal 
MC 363 S (05/07) - County Summary Transmittal 
MC 364 (05/07) - California Department of Aging (CDA) Waiver Referral 

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 368 A (11/10) - Important Information for Medi-Cal Applicants
    Alt: Spanish 
MC 368 M (06/07) - Express Enrollment Supplemental Form for Medi-Cal, Healthy Families and Healthy Kids
    Alt: Spanish 
MC 370 (06/13) - Healthy Families/Medi-Cal Joint Application Order Form 
MC 371 (07/09) - Additional Family Members Requesting Medi-Cal
    Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese
MC 372 (09/09) - Breast and Cervical Cancer Treatment Program (BCCTP)
    Alt: Arabic, Armenian, Chinese, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Vietnamese

MC 373 (09/09) - County Referral to the Breast and Cervical Cancer Treatment Program

​MC 380 (06/18) - Notice of Authorized Representative Appointment

    Alt: Spanish 

​MC 381 (06/18) - Authorized Representative Cancellation Letter

    Alt: Spanish

​MC 382 (06/18) - Appointment of Authorized Representative Form

    Alt: Spanish

​MC 383 (06/18) - Authorized Representative Standard Agreement

    Alt: Spanish

 

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Last modified date: 10/4/2019 3:12 PM