返回 MCED 表格主页​​ 
Medi-Cal 资格部门的表格按表格编号的字母顺序排列如下，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！​​ 

所有孕妇推定资格表格现可在我们的供应商网站上获取，表格如下：
MC 311​​ 

MC 300 表格：​​ 

• MC 306 (11/15) – Appointment of Representative​​ 
  • 替代：西班牙语 (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)​​ 
  
  • 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、瑶语、旁遮普语、俄语、西班牙语、塔加洛语、泰语、乌克兰语、越南语
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  • 大字体：英文
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• 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  
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  • 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 Benefits​​ MC 354 (05/07) – Medi-Cal Contact Update​​ 
  • 替代：西班牙语
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• MC 355 (07/18) – Medi-Cal Request for Information​​ 
  
  • 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 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​​ 
  • 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 372 (12/21) – Breast and Cervical Cancer Treatment Program (BCCTP)​​ 
  
  • 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 373 (12/21) – County Referral to the Breast and Cervical Cancer Treatment Program​​ 
  
• MC 380 (06/18) – Notice of Authorized Representative Appointment​​ 
  
  • 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 381 (06/18) – Authorized Representative Cancellation Letter​​ 
  • 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 382 (06/18) – Appointment of Authorized Representative 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 383 (06/18) – Authorized Representative Standard Agreement​​ 
  • 替代：西班牙语​​