Form Mc 4026 - Request For Eligibility Limited Services
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1State of California—Health and Human Services Agency
Department of Health Care Services
REQUEST FOR ELIGIBILITY LIMITED SERVICES
Name of applicant (last, first)
FOR COUNTY USE ONLY–State Number
County
Aid
Serial Number
FBU Person Number
PART A.
I need/continue to need services related to: (Please check one or more of the following.)
Under Age 12 and Older:
Age 12 Years and Older:
1.
Sexual Assault
3.
Sexually Transmitted Diseases
❒
❒
2.
Pregnancy or Family Planning
4.
Drug or Alcohol Abuse
❒
❒
5.
Outpatient Mental Health*
❒
* If requesting outpatient mental health services, a statement from a mental health professional confirming that you meet the requirements for those services
must be presented to your eligibility worker.
PART B.
I am requesting medical assistance for the month of: ____________/______
Month
Year
PART C. RIGHTS AND RESPONSIBILITIES
1. I understand that I will receive a paper Medi-Cal ID card that is good for one year from the issue date
on the card. This card is for identification only and does not verify eligibility.
2. I understand that my eligibility is good for one month, and each month I need Minor Consent medical
services, I must come back into the welfare department to recertify my eligibility to at least one of the
above services. To allow time for my eligibility worker to process my recertification, I must come in and
complete this form as soon as I know I need to see a doctor or need medical care.
3. I understand that if any of the following happens, I must tell my eligibility worker at my next interview
when I recertify my eligibility:
a. I move out of my parent’s/guardian’s house.
b. I get married.
c. My parent(s) stop supporting me or declaring me as a dependent for tax purposes.
d. I get a job or quit working.
e. My income, such as earnings, increases, decreases, or stops.
f. I get some property; i.e., bank accounts, automobiles, stocks, bonds, trust funds, etc.
g. I give birth or my pregnancy ends for any reason.
4. I understand that I will receive this card and the medical services I have requested without my parents
being contacted.
Signature of Applicant
Date
Signature of County Representative
Worker number
Date
MC 4026 (05/07)
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