返回 MCED 表格主页​​ 

Medi-Cal Eligibility Division forms are listed alphabetically below by form number and may include alternate languages if available. PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing.​​  

2005 年削减赤字法》（DRA）--公民身份要求​​ 

返回 DRA 主页​​ 

On February 8, 2005, President Bush signed into law the DRA which made certain changes to Medicaid (Medi-Cal in California) law. One of those changes was the requirement for individuals declaring to be U.S. citizens or U.S. nationals to show documentary evidence of this fact as well as proof of identity. This website contains information on both the state and federal law regarding this requirement and the implementation of this requirement in California.​​ 

DHCS 0000 表格：​​  

DHCS 0001 (05/09) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity​​  语言阿拉伯语、亚美尼亚语、汉语、波斯语、苗语、柬埔寨语、朝鲜语、老挝语、俄语、西班牙语、他加禄语、越南语​​

DHCS 0002 (01/08) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals​​  语言阿拉伯语、亚美尼亚语、汉语、波斯语、苗语、柬埔寨语、朝鲜语、老挝语、俄语、西班牙语、他加禄语、越南语​​

DHCS 0005 (02/08) – Receipt of Citizenship and Identity Documents​​  语言阿拉伯语、亚美尼亚语、汉语、波斯语、苗语、柬埔寨语、朝鲜语、老挝语、俄语、西班牙语、他加禄语、越南语​​

DHCS 0007 (12/07) – Acceptable Citizenship and Identity Documents​​  语言阿拉伯语、亚美尼亚语、汉语、波斯语、苗语、柬埔寨语、朝鲜语、老挝语、俄语、西班牙语、他加禄语、越南语​​

DHCS 0008 (01/08) – Proof of Citizenship and Identity Requirements – For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application​​  语言阿拉伯语、亚美尼亚语、汉语、波斯语、苗语、柬埔寨语、朝鲜语、老挝语、俄语、西班牙语、他加禄语、越南语​​

DHCS 0009 (09/07) – Affidavit of Identity for U.S. Citizen or National Children Under 18​​  语言阿拉伯语、亚美尼亚语、汉语、波斯语、苗语、柬埔寨语、朝鲜语、老挝语、俄语、西班牙语、他加禄语、越南语​​

DHCS 0010 (01/08) – Affidavit of Identity for U.S. Citizens or National for Disabled Individuals Living in Institutional Care Facilities​​

DHCS 0011 (06/08) – Proof of Acceptable Citizenship or Identity Documents​​  语言阿拉伯语、亚美尼亚语、汉语、波斯语、苗语、柬埔寨语、朝鲜语、老挝语、俄语、西班牙语、他加禄语、越南语​​