Additional Family Members Requesting Medical

ADVERTISEMENT

State of California - Health and Human Services Agency
Department of Health Care Services
Additional Family Members Requesting Medi-Cal
County Use Only
Case name:
Applicant/Caretaker’s Relationship to Child(ren)
Case #
u
Applicant/Caretaker’s Name (First, Middle, Last)
Worker #
Date:
Name on Birth Certificate
Gender
Pregnant?
Yes
No
q
q
Linkage
Due date: _______________ # of babies_____
q
Male
q
Female
SSN
Social Security No.
Date of Birth
Medi-Cal Requested?
q
Yes
q
No
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
PREG
Place of Birth (City/State/Country)
U.S. Citizen or National?
Yes
No
q
q
If No, date arrived in the U.S.
Month
Day
Year
ID
Does this person have a physical, mental, emotional or
Marital Status (check one):
developmental disability?
q
Married
q
Single
q
Widowed
q
Divorced
Other
Yes. Date disability began:
No
q
q
Separated
q
Relationship to Applicant/Caretaker
Linkage
v
Spouse/Other Parent’s Name (First, Middle, Last)
Name on Birth Certificate
Gender
Pregnant?
Yes
No
q
q
SSN
Due date:
# of babies
Male
Female
q
q
Social Security No.
Date of Birth
Medi-Cal Requested?
q
Yes
q
No
PREG
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
Place of Birth (City/State/Country)
U.S. Citizen or National?
Yes
No
q
q
ID
If No, date arrived in the U.S.
Month
Day
Year
Does this person have a physical, mental, emotional
Marital Status (check one):
Other
or developmental disability?
q
Married
q
Single
q
Widowed
q
Divorced
Yes. Date disability began:
No
q
q
q
Separated
Relationship to Applicant/Caretaker
Linkage
w
Child’s Name: (First, Middle, Last) or “Unborn”
Name on Birth Certificate
Gender
Pregnant?
q
Yes
q
No
Due date:
# of babies
Male
Female
q
q
SSN
Social Security No.
Date of Birth
Medi-Cal Requested?
Yes
No
q
q
_____ _____ ______
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
PREG
Place of Birth (City/State/Country)
U.S. Citizen or National?
q
Yes
q
No
If No, date arrived in the U.S.
Month
Day
Year
ID
Child living in home?
Yes
No
Child in school?
Yes
No
q
q
q
q
Medical Support?
Mother’s Name:
Father’s Name:
Yes
No
q
q
CW 2.1 Q
q
Does this child have a physical, mental, emotional or
Is either parent:
CW 2.1
q
developmental disability?
q
Deceased
q
Absent
q
Incapacitated
Not in home, 18-21
q
Yes. Date disability began:
No
q
q
tax dependent
Unemployed
q
MC 371_07/09 (Replaces MC 321 HFP-AP and MC 210S-C)
Page 1 of 2

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2