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加州醫療補助健康保健計劃 資格部門表格按表格編號按字母順序列出如下，並已翻譯成西班牙語

PDF 填寫和列印表格可以在線填寫，並打印成紙本，以簽名並郵寄或親自提交給合資格工作人員進行處理。 

DHCS 表格：西班牙語

• DHCS 0001 (07/09) (Sp) – U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity
• DHCS 0002 (01/08) (Sp) – Proof of Citizenship and Identity–New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals
• DHCS 0005 (02/08) (Sp) – Receipt of Citizenship or Identity Documents
• DHCS 0007 (12/07) (Sp) – Acceptable Citizenship and Identity Documents
• DHCS 0008 (01/08) (Sp) – Proof of Citizenship and Identity Requirements–For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application
• DHCS 0009 (09/07) (Sp) – Affidavit of Identity for U.S. Citizen or National Children Under 18
• DHCS 0011 (06/08) (Sp) – Proof of Acceptable Citizenship or Identity Documents
• DHCS 7068 (07/07) (Sp) – Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives
• DHCS 7077 (01/25) (Sp) – Notice Regarding Standards for Medi-Cal Eligibility
• DHCS 7077 A (07/07) (Eng/Sp) – Notice Regarding Transfer of a Home for Both a Married and an Unmarried Applicant/Beneficiary
• DHCS 7096 (07/07) (Sp) – Department of Developmental Services Waiver Referral
• DHCS 7102 (05/24) (Sp) – Notice Regarding Standards for Medi-Cal Eligibility for Distribution by Insurers, Agents, and Brokers

MC 表格：西班牙語 

• MC 0021 (04/07) (Sp) – Medi-Cal to Healthy Families Bridging Consent Form
• MC 14 A (09/11) (Sp) – Qualified Low-Income Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individuals Application
• 縣名單 (Sp)
• MC 18 (07/07) (Eng/Sp) – Important Notice About Your Medi-Cal Benefits
• MC 174 (05/07) (Eng/Sp) – Medi-Cal Notice to Providers – Clarification of Liability
• MC 176 PA-A (01/09) (Sp) – Medi-Cal Property Assessment Application
• MC 176 PA-1/PA-2 (05/07) (Sp) – Property Worksheet/Assessment for Institutionalized Spouses
• MC 176 S (03/09) (Sp) – Medi-Cal Status Report
• MC 176 TMC (10/08) (Sp) – Transitional Medi-Cal (TMC) Quarterly Status Report
• MC 179 (01/08) (Sp) – Disability Evaluation Form
• MC 209 (05/12) (Sp) – Changes to your Medi-Cal coverage during your pregnancy and after you give birth
• MC 210 A (09/07) (Sp) – Supplement to Statement of Facts for Retroactive Coverage/Restoration
• MC 210 B (08/01) (Sp) – Supplement to Statement of Facts 
• MC 210 PA (05/07) (Sp) – Property Assessment Statement of Facts
• MC 210 PS (05/07) (Sp) – Property Supplement
• MC 210 RV (05/11) (Sp) – Medi-Cal Annual Redetermination
• MC 210 S-C (05/07) (Sp) – Additional Children
• MC 210 S-E (05/07) (Sp) – Student Educational Expenses
• MC 210 S-I – (09/08) (Sp) – Income In-Kind/Housing Verifications 
• MC 210 S-W (07/07) (Sp) – Vocational and Work History
• MC 212 (07/07) (Sp) – Medi-Cal Residency Declaration
• MC 214 (07/07) (Sp) – Important Information About Residency
• MC 215 (10/07) (Sp) – Request for Withdrawal and/or Waiver of Ten-Day Advance Notice
• MC 219 (11/15) (Sp) – Important Information for Persons Requesting Medi-Cal
• MC 220 8pt (06/08) (Sp) – Authorization for Release of Information – 8 point print
• MC 220 14pt (04/08) (Sp) – Authorization for Release of Information – 14 point print
• MC 223 C (06/11) (Sp) – Supplemental Statement of Facts for Medi-Cal Child Applicant Only – Under Age 18
• MC 223 (10/09) (Sp) – Applicant’s supplemental statement of facts for Medi-Cal Adult Applicant Only
• MC 239 DRA-6 (02/10) (Sp) – Info Notice – Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
• MC 250 A (12/14) (Sp) – Application and Statement of Facts for An individual Who is Over 18 and Under 21 and Who Was in Foster Care Placement on His or Her 18th Birthday
• MC 262 (06/07) (Sp) – Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
• MC 263 S-R (02/09) (Sp) – Statement of California Residency
• MC 264 (09/11) (Sp) – Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet
• MC 265 (06/07) (Sp) – Patient Directions for Presumptive Eligibility Application
• MC 267 (05/08) (Sp) – Explanation of Ineligibility for Presumptive Eligibility
• MC 273 (05/07) (Sp) – Work Activity Report
• MC 274 TB (05/07) (Sp) – Medi-Cal Tuberculosis Program Application
• MC 306 (01/08) (Sp) – Appointment of Representative
• MC 322 (09/07) (Sp) – Real and Personal Property – Supplement to Medi-Cal Mail-In Application
• MC 330 (10/24) (Sp) – Newborn Referral (Not an Application for Medi-Cal)
• MC 338 Flyer (05/07) (Sp) – Medi-Cal Program for Workers with Disabilities 250 Percent Working Disabled Program
• MC 354 (05/07) (Sp) – Medi-Cal Contact Update
• MC 355 (06/08) (Sp) – Medi-Cal Request for Information
• MC 356 (05/07) (Sp) – “Safe Arms for Newborns” Medical Questionnaire
• MC 368 A (11/10) (Sp) – Important Information for Medi-Cal Applicants
• MC 368 M (06/07) (Sp) – Supplemental Form for Express Enrollment Applicants
• MC 371 (06/09) (Sp) – Additional Family Members Requesting Medi-Cal
• MC 372 (12/21) (Sp) – Breast and Cervical Cancer Treatment Program (BCCTP) Flyer
• MC 4026 (07/07) (Sp) – Request for Eligibility Limited Services
• MC 4035 (04/08) (Sp) – Medi-Cal Consent Form

MC 信息通告：西班牙語

• MC Information Notice 002 (09/07) (Sp) – Summary Medi-Cal Eligibility (2.18MB)
• MC Information Notice 003 (11/12) (Sp) – Early and Periodic Screening, Diagnosis, and Treatment Services
• MC Information Notice 004 (05/07) (Sp) – Important Information for Medi-Cal Nursing Home Patients
• MC Information Notice 007 (11/22) (Sp) – Medi-Cal General Property Limitations
• MC Information Notice 008 (10/11) (Sp) – Qualified Medicare Beneficiary Program
• MC Information Notice 010 (01/09) (Sp) – Qualified Disabled Working Individual
• MC Information Notice 013 (05/07) (Sp) – Important Information Regarding Your Appeal Rights
• MC Information Notice 017 (07/07) (Sp) – What You Should Know About Your Medi-Cal Disability Application