Rov qab mus rau MCED Forms Main Page​​ 

Cov ntawv thov Medi-Cal Eligibility Division (MCED) tau teev raws li cov tsiaj ntawv hauv qab no los ntawm tus lej ntawv thiab tej zaum yuav muaj lwm hom lus yog tias muaj. Cov ntawv sau thiab luam tawm PDF tuaj yeem ua tiav hauv online thiab luam tawm ua daim ntawv theej kom tau kos npe thiab xa ntawv lossis xa mus rau tus neeg ua haujlwm tsim nyog rau kev ua tiav.​​ 

Hloov tshiab!​​ 

Txhua daim ntawv thov kev pab uas xav tias yuav tau txais kev pab rau cov poj niam cev xeeb tub yuav muab tso rau hauv peb lub vev xaib rau cov ntawv hauv qab no:​​ 

MC 263-SR, MC 264, MC 265, MC 266, MC 267, MC 283, MC 285, & MC 286​​ 

MC 200 Daim Ntawv Thov:​​ 

• MC 209 (05/12) – Kev hloov pauv rau koj qhov kev pov hwm Medi-Cal thaum koj cev xeeb tub thiab tom qab koj yug me nyuam​​ 
  • Lwm hom lus: Arabic, Armenian, Suav, Farsi, Hmoob, Cambodian, Kauslim, Mev, Tagalog, Nyab Laj​​ 
• MC 210 A (09/07) – Ntxiv rau Cov Lus Qhia Txog Kev Them Nqi/Kev Kho Dua Tshiab​​ 
  • Alt: Spanish​​ 
• MC 210 B (05/07) – Supplement to Statement of Facts (PICKLE Eligibility/Determination)​​ 
  • Alt: Spanish​​ 
• MC 210 PA (05/07) – Cov Lus Qhia Txog Kev Ntsuam Xyuas Vaj Tse​​ 
  • Alt: Spanish​​ 
• MC 210 RV (10/20) – Kev Txiav Txim Dua Txhua Xyoo ntawm Medi-Cal​​ 
  • Lwm yam: Arabic, Armenian, Cambodian, Suav, Farsi, Hindi, Hmoob, Nyiv Pooj, Kauslim, Laotian, Mien, Punjabi, Lavxias teb sab, Mev, Tagalog, Thaib, Ukrainian, Nyab Laj
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• MC 210 S-C (05/07) – Cov Menyuam Ntxiv (Ntxiv rau Daim Ntawv Qhia Txog Medi-Cal, MC 210) (Eng/Sp)​​ 
• MC 210 S-E (05/07) – Cov Nqi Kawm Ntawv Rau Cov Tub Ntxhais Kawm (Ntxiv rau Cov Lus Qhia Txog Medi-Cal, MC 210)​​ 
  • Alt: Spanish​​ 
• MC 210 S-I (09/08) - Kev Txheeb Xyuas Nyiaj Tau Los Hauv Hom/Tsev Nyob (Ntxiv rau MC 210 Cov Lus Qhia Tseeb) (Eng/Sp)​​ 
• MC 210 S-W (05/07) – Keeb Kwm Kev Ua Haujlwm thiab Kev Ua Haujlwm​​ 
  • Alt: Spanish​​ 
• MC 212 (05/07) – Daim Ntawv Tshaj Tawm Txog Kev Nyob Hauv Medi-Cal (Eng/Sp)​​ 
• MC 214 (05/07) – Cov Lus Qhia Tseem Ceeb Txog Kev Nyob Hauv Tsev Kawm Ntawv​​ 
  • Alt: Spanish​​ 
• MC 215 (05/07) – Daim Ntawv Thov Kom Rho Tawm thiab/lossis Tso Tseg Daim Ntawv Ceeb Toom Ua Ntej Kaum Hnub​​ 
  • Lwm yam: Mev (10/07)​​ 
• MC 216 (10/20) – Pre-Populated Renewal Form​​ 
  • Alt: Arabic, Armenian, Cambodian, Suav, Farsi, Hindi, Hmong, Japanese, Korean, Laotian, Mien, Punjabi, Russian, Spanish, Tagalog, Thaib, Ukrainian, Nyab Laj​​ 
• MC 217 (10/20) – Pre-Populated Renewal Form​​ 
  • Alt: Arabic, Armenian, Cambodian, Suav, Farsi, Hindi, Hmong, Japanese, Korean, Laotian, Mien, Punjabi, Russian, Spanish, Tagalog, Thaib, Ukrainian, Nyab Laj​​ 
• MC 219 (11/15) – Cov Lus Qhia Tseem Ceeb rau Cov Neeg Thov Medi-Cal (Sau Ntawv Loj, Lus Askiv)​​ 
  • Alt: Arabic, Armenian, Suav, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Nyab Laj​​ 
• MC 220 8pt (06/08) – Kev Tso Cai Rau Kev Tso Tawm Cov Ntaub Ntawv​​ 
  • Alt: Spanish​​ 
• MC 220 14pt (04/08) – Kev Tso Cai Rau Kev Tso Tawm Cov Ntaub Ntawv (Sau Ntawv Loj)​​ 
  • Alt: Spanish​​ 
• MC 221 LA (02/14) – Kev Txiav Txim Siab Txog Kev Tsis Taus thiab Kev Xa Mus Rau Lwm Tus Neeg (Los Angeles)​​ 

• MC 222 LA (02/14) – DDSD Tos Txais Cov Ntaub Ntawv Hloov Tshiab (Los Angeles)​​ 
• MC 223 (10/09) – Cov Lus Qhia Ntxiv ntawm Tus Neeg Thov Kev Pab rau Medi-Cal​​ 
  • Alt: Arabic, Armenian, Suav, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Nyab Laj​​ 
• MC 223 C (06/11) – Cov Lus Qhia Ntxiv rau Tus Neeg Thov Medi-Cal Me Nyuam Xwb - Hnub Nyoog Qis Dua 18 Xyoo (MC 223C) Cov Lus Qhia​​ 
  • Alt: Arabic, Armenian, Suav, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Nyab Laj​​ 
• MC 224 A (06/07) – Daim Ntawv Qhia Txog Kev Them Nyiaj Ntau Dhau ntawm Medi-Cal Cov Nyiaj Tau Los lossis Lwm Yam Kev Pov Hwm Kho Mob​​ 
• 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) – Daim Ntawv Qhia Txog Kev Them Nyiaj Ntau Dhau ntawm Medi-Cal Ntxiv – Kev Tsis Tsim Nyog Tag Nrho Cov Khoom Vaj Tse lossis Kev Tsis Tsim Nyog Rau Ib Qib Kev Pabcuam Tshwj Xeeb​​ 
• MC 239 DRA-6 (02/10) – Daim Ntawv Ceeb Toom Txog Cov Ntaub Ntawv – Tsis Muaj Peev Xwm Txheeb Xyuas Tau Tebchaws Meskas (Tebchaws Meskas) Kev Ua Pej Xeem/Tus Kheej Los Ntawm Lub Chaw Haujlwm Saib Xyuas Kev Ruaj Ntseg Hauv Zej Zog​​ 
  • Alt: Arabic, Armenian, Suav, Farsi, Hmong, Cambodian, Korean, Russian, Spanish, Tagalog, Nyab Laj​​ 
• MC 250 (05/07) – Daim Ntawv Thov thiab Cov Lus Qhia Txog Qhov Tseeb rau Tus Menyuam Tsis Nyob Nrog Niam Txiv lossis Tus Txheeb Ze thiab rau Tus Neeg Uas Lub Chaw Haujlwm Pej Xeem Muaj Lub Luag Haujlwm Nyiaj Txiag​​ 
• MC 250 A (12/14) – Daim Ntawv Thov Medi-Cal rau Cov Hluas Uas Tau Saib Xyuas Yav Dhau Los​​ 
  • Alt: Spanish​​ 

• MC 262 (06/07) – Kev Txiav Txim Dua Rau Cov Neeg Tau Txais Medi-Cal (Kev Saib Xyuas Mus Ntev Hauv Tus Kheej Lub MFBU)​​ 
  • Alt: Spanish​​ 
• MC 272 (05/07) – Daim Ntawv Ua Haujlwm SGA​​ 
• MC 273 (05/07) – Daim Ntawv Qhia Txog Kev Ua Haujlwm​​ 
  • Alt: Spanish​​ 
• MC 274 TB (05/07) – Daim Ntawv Thov Kev Pab Cuam Kab Mob Ntsws Medi-Cal​​ 
  • Alt: Spanish​​ 
• MC 278 TB (05/07) – Daim Ntawv Ua Haujlwm Txog Kev Kho Mob Ntsws (TB) Rau Cov Neeg Laus​​ 
• MC 279 TB (05/07) – Daim Ntawv Ua Haujlwm Txog Kev Kho Mob Ntsws (TB) Rau Menyuam​​ 
• MC 280 TB (05/07) – Daim Ntawv Ua Haujlwm Txog Kev Tsim Nyog Nyiaj Txiag Rau Kev Pab Cuam Kab Mob Ntsws (TB) – Tus Menyuam Tsim Nyog Uas Muaj Niam Txiv Tsis Tsim Nyog Lossis Cov Niam Txiv Uas Muaj Cai​​ 
• MC 281 TB (05/07) – Daim Ntawv Ua Haujlwm Txog Kev Tsim Nyog Tau Nyiaj Los Ntawm Kev Pab Cuam Kab Mob Ntsws (TB)​​ 
• MC 282 TB (05/07) – Daim Ntawv Ua Haujlwm Txog Kev Tsim Nyog Tau Nyiaj Los Ntawm Kev Pab Cuam Kab Mob Ntsws (TB)​​