Medi-Cal Eligibility Division Translated Forms: Tagalog​​ 

Bumalik sa Pangunahing Pahina ng Mga Translated Forms​​ 

Ang mga form ng Medi-Cal Eligibility Division (MCED) ay nakalista sa ibaba, ayon sa alpabeto, ayon sa numero ng form at naisalin na sa Tagalog.​​  

Ang PDF fill at print na mga form ay maaaring kumpletuhin online at i-print sa hardcopy para pirmahan at ipadala sa koreo o isumite nang personal sa isang eligibility worker para sa pagproseso.​​  

Mga Form ng DHCS: Tagalog​​ 

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

 Mga Form ng MC: Tagalog​​ 

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

Mga Paunawa sa Impormasyon ng MC: Tagalog​​ 

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