Additional Family Members Requesting Medi-Cal - California Department Of Health Care Services Page 2
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1
2q DHCS 6155
x
Is anyone currently covered by health/dental insurance or Medicare?
Yes
No
q
q
If so, who?
OHC Code:
DHCS 6268
y
Has anyone filed a lawsuit because of an accident or injury?
Yes
No
q
q
q
MC 210 A
z
Do you or any family member want Medi-Cal to cover medical expenses in the last three months
q
Retroactive Coverage
and wish to apply for Medi-Cal?
q
Yes
q
No
List name(s):
Month(s) of coverage:
Month
Month
Month
1
2
3
CW 5
Have you or any family member ever been in U.S. military service?
Yes
No
q
q
q
If Yes, who? Name(s):
Relationship:
The Medi-Cal program may share your information unless you check the box below:
•
We will share your child’s application with Healthy Families if your child no longer qualifies for free Medi-Cal in the future. If you
do not want us to share it, check here
q
•
We will share your child’s application with Healthy Kids or similar county program if your child does not qualify for
full-scope Medi-Cal. If you do not want us to share it, check here
q
Family Income: List the income of every person listed in this application. Include child support and spousal support received.
(Use a separate line for each source of income.)
Name of person with Income
Source of Income
How often is income
How much is
Social Security No.
received?
the income?
(Children who are in school do not have to list
(Job, social security,
(Optional)
their income from a job.)
pension, etc.)
(Weekly, biweekly, monthly)
(Total gross
income)
$
$
$
$
$
Expenses: List the monthly expenses for all persons listed above.
Child Day Care or Disabled Dependent Care
For (child or dependent’s name): __________________________________________ Age: ______ Amount Paid: _____________
How Often? ______________
For (child or dependent’s name): __________________________________________ Age: _______ Amount Paid: ____________
How Often? _____________
Court-ordered child support
Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________
Court-ordered spousal support
Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________
Please note that additional information about your property, income and/or resources may be required if applicable.
I certify that I have read and understand the information above. I also certify that the information I have given on this form is true and
correct.
Signature _____________________________________________________________________ Date: ________________
Page 2 of 2
MC 371_07/09 (Replaces MC 321 HFP-AP and MC 210S-C)
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