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

Medi-Cal Eligibility Division (MCED) cov ntaub ntawv tau teev tseg hauv qab no, cov tsiaj ntawv, los ntawm tus lej thiab tau muab txhais ua lus Nyab Laj.​​  

PDF sau thiab luam cov ntawv tuaj yeem ua tiav hauv online thiab luam tawm rau cov ntawv tawv tawv kom kos npe thiab xa hauv lossis xa tuaj rau tus neeg ua haujlwm tsim nyog rau kev ua haujlwm.​​ 

DHCS Forms: Nyab Laj​​ 

• DHCS 0001 (01/08) (Vie) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity​​ 
• DHCS 0002 (01/08) (Vie) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries Who Are U.S. Citizens or Nationals​​ 
• DHCS 0005 (02/08) (Vie) – Receipt of Citizenship or Identity Documents​​ 
• DHCS 0007 (12/07) (Vie) – Acceptable Citizenship and Identity Documents​​ 
• DHCS 0008 (01/08) (Vie) – Proof of Citizenship and Identity Requirements for Children Who Are U.S. Citizens or Nationals Filling Out the Healthy Families​​ 
• DHCS 0009 (09/07) (Vie) – Affidavit of Identity for U.S. Citizen or National Children Under 18​​ 
• DHCS 0011 (06/08) (Vie) – Proof of Citizenship or Identity Documents​​ 

MC Forms: Nyab Laj​​ 

• MC 0021 (04/07) (Vie) – Medi-Cal to Healthy Families Bridging Consent Form​​ 
• MC 176 S (03/09) (Vie) – Medi-Cal Status Report​​ 
• MC 209 (05/12) (Vie) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth​​ 
• MC 210 RV (05/11) (Vie) – Medi-Cal Annual Redetermination​​ 
• MC 219 (11/15) (Vie) – Important Information for Persons Requesting Medi-Cal​​ 
• MC 223 C (06/11) (Vie) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only – Under Age 18​​ 
• MC 223 (10/09) (Vie) – Applicant’s supplemental statement of facts for Medi-Cal Adult Applicant Only​​ 
• MC 239 DRA-6 (02/10) (Vie) – Information Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration​​ 
• MC 264 (09/11) (Vie) – Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet​​ 
• MC 371 (06/09) (Vie) – Additional Family Members Requesting Medi-Cal​​ 
• MC 372 (12/21) (Vie) – Breast and Cervical Cancer Treatment Program (BCCTP) Flyer​​ 
• MC 4035 (04/08) (Vie) – Medi-Cal Consent Form​​ 

MC Cov Ntaub Ntawv Ceeb Toom: Nyab Laj​​ 

• MC Information Notice 003 (05/13) (Vie) – Early and Periodic Screening, Diagnosis, and Treatment Services​​