Home Forms, Laws, and Publications Forms Medi-Cal Eligibility Division Translated Forms: Farsi

Medi-Cal Eligibility Division Translated Forms: Farsi

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

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DHCS 양식: Farsi

DHCS 0001 (01/08) (Far) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity
DHCS 0002 (01/08) (Far) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals
DHCS 0005 (02/08) (Far) – Receipt of Citizenship or Identity Documents
DHCS 0007 (12/07) (Far) – Acceptable Citizenship and Identity Documents
DHCS 0008 (01/08) (Far) – Proof of Citizenship and Identity Requirements–For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application
DHCS 0004 (06/07) (Far) – Request for California Birth Record
DHCS 0005 (02/08) (Far) – Receipt of Citizenship or Identity Documents
DHCS 0006 (08/07) (Far) – Proof of Citizenship and Identity
DHCS 0007 (12/07) (Far) – Acceptable Citizenship and Identity Documents
DHCS 0008 (01/08) (Far) – Proof of Citizenship and Identity Requirements–For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application
DHCS 0009 (09/07) (Far) – Affidavit of Identity for U.S. Citizen or National Children Under 18
DHCS 0011 (06/08) (Far) – Proof of Acceptable Citizenship or Identity Documents
MC 0021 (04/07) (Far) – Medi-Cal to Healthy Families Bridging Consent Form

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

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