Medi-Cal Eligibility Division Translated Forms: Tagalog​​ 

Rov qab mus rau Phau Ntawv Txhais Lus Lub Ntsiab​​ 

Medi-Cal Eligibility Division (MCED) forms are listed below, alphabetically, by form number and has been translated into Tagalog.​​  

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.​​  

DHCS Forms: Tagalog​​ 

• DHCS 0001 (01/08) (Tag) – Cov pej xeem Asmeskas thiab cov neeg nyob hauv tebchaws uas thov Medi-Cal yuav tsum qhia pov thawj tias yog pej xeem thiab yog tus kheej​​ 
• DHCS 0002 (01/08) (Tag) - Pov Thawj Txog Kev Ua Neeg Amelikas Thiab Tus Kheej - Cov Kev Cai Tshiab Rau Cov Neeg Tau Txais Medi-Cal Uas Yog Neeg Amelikas Los Yog Neeg Hauv Tebchaws Meskas​​ 
• DHCS 0005 (02/08) (Tag) - Daim Ntawv Txais Cov Ntawv Pov Thawj Ua Neeg Amelikas lossis Daim Ntawv Qhia Tus Kheej​​ 
  
• DHCS 0007 (12/07) (Tag) - Cov Ntaub Ntawv Txog Kev Ua Neeg Amelikas Thiab Kev Txheeb Xyuas Tus Kheej Uas Txais Tau​​  
  
• DHCS 0008 (01/08) (Tag) - Cov Kev Cai Pov Thawj Txog Kev Ua Neeg Amelikas thiab Kev Txheeb Xyuas Tus Kheej rau Cov Menyuam Uas Yog Neeg Amelikas lossis Neeg Tebchaws Meskas Ua Tus Sau Cov Tsev Neeg Noj Qab Nyob Zoo​​  
• DHCS 0009 (09/07) (Tag) – Affidavit of Identity for U.S. Citizen or National Children Under 18​​ 
• DHCS 0011 (06/08) (Tag) - Cov Ntawv Pov Thawj Txog Kev Ua Neeg Amelikas lossis Daim Ntawv Qhia Tus Kheej Uas Tau Txais​​  

 MC Forms: Tagalog​​ 

• MC 0021 (04/07) (Tag) – Daim Ntawv Pom Zoo Rau Medi-Cal Rau Cov Tsev Neeg Noj Qab Haus Huv​​ 
• MC 176 S (03/09) (Tag) – Medi-Cal Status Report​​ 
• MC 209 (05/12) (Tag) – Kev hloov pauv rau koj qhov kev pov hwm Medi-Cal thaum koj cev xeeb tub thiab tom qab koj yug me nyuam​​ 
• MC 210 RV (05/11) (Tag) – Medi-Cal Kev Txiav Txim Txhua Xyoo​​ 
• MC 219 (11/15) (Tag) – Important Information For Persons Requesting Medi-Cal​​ 
• MC 223 C (06/11) (Tag) - Cov Lus Qhia Ntxiv rau Tus Neeg Thov Medi-Cal Me Nyuam Xwb​​ 
• MC 223 (10/09) (Tag) – Applicant’s supplemental statement of facts for Medi-Cal Adult Applicant Only​​  
• MC 239 DRA-6 (02/10) (Tag) - Daim Ntawv Ceeb Toom - Tsis Muaj Peev Xwm Txheeb Xyuas Tebchaws Meskas (US) Kev Ua Pej Xeem/Tus Kheej Los Ntawm Lub Chaw Haujlwm Saib Xyuas Kev Ruaj Ntseg Hauv Zej Zog​​ 
• MC 264 (09/11) (Tag) - Kev Tsim Nyog Rau Cov Poj Niam Cev Xeeb Tub Daim Ntawv Qhia Txog Tus Neeg Mob​​ 
• MC 371 (06/09) (Tag) - Cov Tswv Cuab Ntxiv Hauv Tsev Neeg Thov Medi-Cal​​ 
• MC 372 (12/21) (Tag) – Daim Ntawv Qhia Txog Kev Kho Mob Cancer Mis thiab Cervical Cancer (BCCTP)​​ 
• MC 4035 (04/08) (Tag) – Daim Ntawv Pom Zoo Medi-Cal​​  

MC Cov Ntaub Ntawv Ceeb Toom: Tagalog​​ 

• Daim Ntawv Ceeb Toom Txog MC 003 (05/13) (Tag) - Kev Tshuaj Xyuas Thaum Ntxov thiab Tsis Tu Ncua, Kev Kuaj Mob, thiab Kev Kho Mob​​