Medi-Cal Request For Information Page 2
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2MEDI-CAL REQUEST FOR INFORMATION
WE NEED ONLY THE INFORMATION REQUESTED BELOW.
Income
A copy of the most recent pay stub or statement from your employer about your job (how much you are
paid, how often you are paid, how many hours you work) for each of your jobs (if you have more than one)
or a copy of your most recent tax return. This will help us decide if you are eligible for free Medi-Cal or will
have a “share-of-cost.”
Your signed statement about your job (or jobs) if you do not get pay stubs and cannot get a statement from
your employer (or employers).
Schedule C if self-employed.
Proof of unemployment or disability benefits—a copy of benefits stub or award letter.
Proof of social security benefits received—a copy of paid benefits stub or award letter.
Income Deductions
A copy of checks or receipts of child care, child support, alimony, or health insurance paid.
Personal or Real Property
A copy of vehicle registration (if more than one vehicle owned).
A copy of your most recent bank statement (checking, savings account, etc.)
A copy of life insurance policy, stocks, bonds, retirement account statement.
Information on Person(s) Requesting Medi-Cal
(If you are an immigrant and don’t have a social security card or immigration documentation to give us, you may still qualify for
emergency and pregnancy-related services.)
Social security number for:____________________________.
A copy of your California driver’s license or a photo ID for:______________________________.
A copy of immigration documentation or card (if card, a copy of both sides) for:______________________.
Residence
Verification of your current address (rent receipt, utility bill, etc.).
Disability/Incapacity
Social security award letter for disability.
Other proof that you have a physical, mental, or emotional disability that will last 12 months or more.
Proof of incapacity—such as a doctor’s statement that you can’t work for at least 30 days.
Other
____________________________________________________________________________________
Check this box if you think you or any family member receiving Medi-Cal is disabled.
We must receive this information by _______________. Otherwise, we may begin the process to stop
your Medi-Cal benefits! (A prepaid self-addressed envelope is provided for your convenience.)
HELP US TO KEEP IN TOUCH WITH YOU!
Call your eligibility worker if you have a change of address or telephone number.
(The name and telephone number are listed on the other side of this page at the top.)
MC 355 (05/07)
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