Department of Health Care Services
State of California—Health and Human Services Agency
Medi-Cal Program
MEDI-CAL REQUEST FOR INFORMATION
ATTENTION: READ THIS SIDE FIRST
Notice date:____________________________________
Case number: __________________________________
Worker name: __________________________________
Worker number: ________________________________
Worker telephone number: ________________________
Office hours: ___________________________________
Notice for: _____________________________________
The information requested on the back of this form is needed to complete our review of your
continued eligibility for Medi-Cal benefits.
REMEMBER!!!
Even if you are employed you may be eligible to receive Medi-Cal benefits.
Receipt of Medi-Cal does not count against any CalWORKs time limits.
You do not have to receive CalWORKs to receive Medi-Cal benefits.
IMPORTANT!!!
You may still be eligible if you are:
under the age of 21;
at least age 65 or older;
disabled;
blind;
pregnant;
a parent or caretaker relative of a child (under the age of 21) who has at least one parent
either absent, deceased, incapacitated, or unemployed/underemployed;
have tuberculosis or receive dialysis;
living in a long-term care facility;
a refugee who has been in the country eight months or less;
receiving SSI benefits;
receiving CalWORKs benefits; or
eligible for special programs (i.e., TMC, QMB, percentage programs, etc.).
If you have any questions or need more information about this form, call your eligibility worker whose
name and telephone number are listed at the top of this form.
IMPORTANT!
PLEASE READ THE OTHER SIDE OF THIS FORM.
MC 355 (05/07)