ກັບໄປທີ່ໜ້າຫຼັກແບບຟອມ MCED
ແບບຟອມຂອງພະແນກການມີສິດໄດ້ຮັບຂອງ Medi-Cal ແມ່ນລະບຸຕົວໜັງສືຢູ່ລຸ່ມນີ້ຕາມຕົວເລກຂອງແບບຟອມ ແລະອາດຈະລວມເອົາພາສາສຳຮອງຖ້າມີ. ແບບຟອມຕື່ມຂໍ້ມູນ PDF ແລະພິມອາດຈະສໍາເລັດອອນໄລນ໌ແລະພິມອອກເປັນ hardcopy ເພື່ອລົງນາມແລະສົ່ງໃນໄປສະນີຫຼືສົ່ງດ້ວຍຕົນເອງກັບພະນັກງານທີ່ມີສິດໄດ້ຮັບການດໍາເນີນການ.

ອັບເດດ!

ແບບຟອມການມີສິດໄດ້ຮັບສົມມຸດຕິຖານທັງໝົດສໍາລັບແມ່ຍິງຖືພາໃນປັດຈຸບັນຈະມີຢູ່ໃນເວັບໄຊທ໌ຜູ້ໃຫ້ບໍລິການຂອງພວກເຮົາສໍາລັບແບບຟອມຕໍ່ໄປນີ້:
MC 311

MC 300 ແບບຟອມ:

• MC 306 (11/15) – Appointment of Representative
  • Alt: ແອສປາໂຍນ (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 SheetMC 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 (10/24) – Newborn Referral (Not an Application for Medi-Cal (fillable)
  
  • Alt: Arabic, Armenian, Cambodian, Chinese, Farsi, Hindi, Hmong, Japanese, Korean, Laotian, Mien, Punjabi, Russian, Spanish, Tagalog, Thai, Ukrainian, Vietnamese
    
  • ຕົວອັກສອນໃຫຍ່: ພາສາອັງກິດ
    
• 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 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 BenefitsMC 354 (05/07) – Medi-Cal Contact Update
  • Alt: ແອສປາໂຍນ  
    
• MC 355 (07/18) – Medi-Cal Request for Information
  
  • Alt: Arabic, Armenian, ກໍາປູເຈຍ, ຈີນ, Farsi, ຮິນ ດູ , ມົ້ງ, ຍີ່ປຸ່ນ, ເກົາຫຼີ, Laotian, Mien, Punjabi, ລັດເຊຍ, ສະເປນ, Tagalog, ໄທ, ອູແກຣນ, ຫວຽດນາມ
• 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, ຈີນ, Farsi, ມົ້ງ, ກໍາປູເຈຍ, ເກົາຫຼີ, ລັດເຊຍ, ແອສປາໂຍນ, Tagalog, ຫວຽດນາມ 
• MC 372 (12/21) – Breast and Cervical Cancer Treatment Program (BCCTP)
  
  • Alt: Arabic, Armenian, ກໍາປູເຈຍ, ຈີນ, Farsi, ຮິນ ດູ , ມົ້ງ, ຍີ່ປຸ່ນ, ເກົາຫຼີ, Laotian, Mien, Punjabi, ລັດເຊຍ, ສະເປນ, Tagalog, ໄທ, ອູແກຣນ, ຫວຽດນາມ
• MC 373 (12/21) – County Referral to the Breast and Cervical Cancer Treatment Program
  
• MC 380 (06/18) – Notice of Authorized Representative Appointment
  
  • Alt: Arabic, Armenian, ກໍາປູເຈຍ, ຈີນ, Farsi, ຮິນ ດູ , ມົ້ງ, ຍີ່ປຸ່ນ, ເກົາຫຼີ, Laotian, Mien, Punjabi, ລັດເຊຍ, ສະເປນ, Tagalog, ໄທ, ອູແກຣນ, ຫວຽດນາມ 
• MC 381 (06/18) – Authorized Representative Cancellation Letter
  • Alt: Arabic, Armenian, ກໍາປູເຈຍ, ຈີນ, Farsi, ຮິນ ດູ , ມົ້ງ, ຍີ່ປຸ່ນ, ເກົາຫຼີ, Laotian, Mien, Punjabi, ລັດເຊຍ, ສະເປນ, Tagalog, ໄທ, ອູແກຣນ, ຫວຽດນາມ 
• MC 382 (06/18) – Appointment of Authorized Representative Form
  • Alt: Arabic, Armenian, ກໍາປູເຈຍ, ຈີນ, Farsi, ຮິນ ດູ , ມົ້ງ, ຍີ່ປຸ່ນ, ເກົາຫຼີ, Laotian, Mien, Punjabi, ລັດເຊຍ, ສະເປນ, Tagalog, ໄທ, ອູແກຣນ, ຫວຽດນາມ 
• MC 383 (06/18) – Authorized Representative Standard Agreement
  • Alt: ແອສປາໂຍນ