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Medi-Cal 资格部门 (MCED) 表格按表格编号的字母顺序列出，并且可能包含其他语言（如有）。PDF 填写和打印表格可以在线填写并打印为硬拷贝，然后签名并邮寄或亲自提交给资格审查工作人员进行处理。

更新！

现在，我们的提供商网站上将提供以下孕妇推定资格表格：

MC 263-SR、MC 264、MC 265、MC 266、MC 267、MC 283、MC 285 和 MC 286

MC 200 表格：

• MC 209 (05/12) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
  •  其他：阿拉伯语、亚美尼亚语、中文、波斯语、苗语、柬埔寨语、韩语、西班牙语、塔加洛语、越南语
• MC 210 A (09/07) – Supplement to Statement of Facts for Retroactive Coverage/Restoration
  •  其他：西班牙语
• MC 210 B (05/07) – Supplement to Statement of Facts (PICKLE Eligibility/Determination)
  •  其他：西班牙语
• MC 210 PA (05/07) – Property Assessment Statement of Facts
  •  其他：西班牙语
• MC 210 RV (10/20) – Medi-Cal Annual Redetermination
  • Alt: Arabic, Armenian, Cambodian, Chinese,  Farsi, Hindi, Hmong, Japanese, Korean,  Laotian, Mien,  Punjabi, Russian, Spanish, Tagalog, Thai, Ukrainian, Vietnamese
    
• MC 210 S-C (05/07) – Additional Children (Supplement to the Medi-Cal Statement of Facts, MC 210) (Eng/Sp)
• MC 210 S-E (05/07) – Student Educational Expenses (Supplement to Medi-Cal Statement of Facts, MC 210)
  • 其他：西班牙语
• MC 210 S-I (09/08) – Income In-Kind/Housing Verification (Supplement to the MC 210 Statement of Facts) (Eng/Sp)
• MC 210 S-W (05/07) – Vocational and Work History
  • 其他：西班牙语
• MC 212 (05/07) – Medi-Cal Residency Declaration (Eng/Sp)
• MC 214 (05/07) – Important Information About Residency
  • 其他：西班牙语
• MC 215 (05/07)  – Request for Withdrawal and/or Waiver of Ten-Day Advance Notice
  • Alt: Spanish (10/07)
• MC 216 (10/20) – Pre-Populated Renewal Form
  • Alt: Arabic, Armenian, Cambodian, Chinese, Farsi, Hindi,  Hmong, Japanese, Korean,  Laotian, Mien,  Punjabi, Russian,  Spanish, Tagalog, Thai, Ukrainian,  Vietnamese
• MC 217 (10/20) – Pre-Populated Renewal Form
  • 其他： 阿拉伯语 、 亚美尼亚 语、 柬埔寨语 、 中文 、 波斯语 、 印地语 、 苗语 、 日语 、韩语、 老挝语、瑶族语、旁遮普 语 、 俄语 、西班牙语 、 塔加洛 语 、 泰语 、 乌克兰语 、 越南语
• MC 219 (11/15) – Important Information for Persons Requesting Medi-Cal (Large Print, Eng)
  • 其他：阿拉伯语、亚美尼亚语、中文、波斯语、苗语、柬埔寨语、韩语、俄语、西班牙语、塔加洛语、越南语
• MC 220 8pt (06/08) – Authorization for Release of Information
  • 其他：西班牙语
• MC 220 14pt (04/08) – Authorization for Release of Information (Large Print)
  • 其他：西班牙语
• MC 221 LA (02/14) – Disability Determination and Transmittal (Los Angeles)

• MC 222 LA (02/14) – DDSD Pending Information Update (Los Angeles)
• MC 223 (10/09) – Applicant’s Supplemental Statement of Facts for Medi-Cal
  • 其他：阿拉伯语、亚美尼亚语、中文、波斯语、苗语、柬埔寨语、韩语、俄语、西班牙语、塔加洛语、越南语
• MC 223 C (06/11) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only- Under Age 18 (MC 223C) Instructions
  • 其他：阿拉伯语、亚美尼亚语、中文、波斯语、苗语、柬埔寨语、韩语、俄语、西班牙语、塔加洛语、越南语
• MC 224 A (06/07) – Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage
• MC 224 A-S (05/07) – Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet Income or Other Health Coverage
• MC 224 B (06/07) – Medi-Cal Potential Overpayment Reporting Work Sheet – Property Total Ineligibility or Ineligibility For A Specific Level of Services
• MC 224 B-S (05/07) – Supplemental Medi-Cal Potential Overpayment Reporting Work Sheet – Property Total Ineligibility or Ineligibility For A Specific level of Services
• MC 239 DRA-6 (02/10) – Information Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
  • 其他：阿拉伯语、亚美尼亚语、中文、波斯语、苗语、柬埔寨语、韩语、俄语、西班牙语、塔加洛语、越南语
• MC 250 (05/07) – Application and Statement of Facts for Child Not Living with a Parent or Relative and for Whom a Public Agency is Assuming Some Financial Responsibility
• MC 250 A (12/14) – Application for Medi-Cal for Former Foster Care Youth
  • 其他：西班牙语

• MC 262 (06/07) – Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
  • 其他：西班牙语
• MC 272 (05/07) – SGA Work Sheet
• MC 273 (05/07) – Work Activity Report
  • 其他：西班牙语
• MC 274 TB (05/07) – Medi-Cal Tuberculosis Program Application
  • 其他：西班牙语
• MC 278 TB (05/07) – Tuberculosis (TB) Program Property Worksheet Adult
• MC 279 TB (05/07) – Tuberculosis (TB) Program Property Worksheet Child
• MC 280 TB (05/07) – Tuberculosis (TB) Program Financial Eligibility Worksheet – Eligible Child with Ineligible Parent or Parent(s)
• MC 281 TB (05/07) – Tuberculosis (TB) Program Income Eligibility Worksheet
• MC 282 TB (05/07) – 结核病 (TB) 项目收入资格工作表