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State of California—Health and Human Services Agency

Department of Health Care Servic

EXPRESS ENROLLMENT SUPPLEMENTAL FORM

Case name:

Case number:

FOR MEDI-CAL, HEALTHY FAMILIES and HEALTHY KIDS

Eligibility Worker:

E. W. phone #:

Please complete the questions below for each child requesting health coverage. Return this information with any necessary

documents in the enclosed postage-paid envelope no later than _____________________________ or your child(ren)’s eligibility for

Medi-Cal benefits may be discontinued or denied.

Child 1

Child 2

Child 3

Child 4

Child 5

1. Name of child

First, middle initial, last

2. Social security number

IMPORTANT: If your child does not have a social security number (SSN), you can apply for a SSN now and provide it to us within 60 days. Your child may be

eligible to receive emergency-related Medi-Cal if he/she is unable to get a SSN.

3. U.S. Citizen or national?

Yes

If NO, please check if the child

has satisfactory immigration

Satisfactory

status and write the date of

immigration status

entry into the United States.

____/____/____

Date of entry

If your child is not a U.S. Citizen or national, send proof (copies) of his/her immigration status or a receipt from INS showing you have applied to replace

a lost document. You may send the document now or within 30 days.

4. Does this child have other

Yes

health, dental, or vision

insurance?

If YES, please complete the enclosed “Health Insurance Questionnaire” form (DHS 6155). If the children are all covered by the same insurance plan, only one

form is required per family. If the children have separate insurance plans, separate forms are required. IMPORTANT: Your child can still be eligible for

Medi-Cal even if he/she has other health coverage.

Yes

Lost job

5. Was a child insured by an

Moved, no insurance

Moved, no insur-

Moved, no insurance

available

ance available

available

employer in the last 3

Employer ended

months?

benefits to all

employees

COBRA coverage

If YES, check the main reason

ended

why health insurance stopped

Other ________

and give the date it stopped.

_______________

_____/_____/____

Date Stopped

6. Do you want Medi-Cal to

Yes

cover any medical expenses

this child had in the last

3 months?

Yes

7. Is anyone else in your family interested in applying for Medi-Cal?

Provide the following information if a box is checked.

If you pay for child care services, child support, health insurance premiums, or have self-employment expenses, send a copy of your most recent

payment/expenses. Proof of these expenses can be used to reduce the income we count for a Medi-Cal determination. A copy of your income from

work, Workers Compensation, or state disability benefits may allow you an additional deduction.

________________________________________________________________________________________________________

Other:

If you have any questions or need additional information, please contact your Medi-Cal Eligibility Worker listed on the top right corner of this form.

I understand and agree to the following: If my child(ren) is not eligible for no-cost full-scope Medi-Cal, this form may be shared with low-cost

Healthy Families or Healthy Kids to determine if he or she is eligible for health coverage through these programs. I will be contacted for more

information if my child(ren)’s application is forwarded.

Do not forward my application to the Healthy Families or Healthy Kids.

(check box)

Declaration and Signature

I declare under penalty of perjury under the laws of the State of California that the answers I have given in this application, the declarations made, and the

documents submitted are true and correct to the best of my knowledge and belief. I declare that I have received, read, and understand the attachment titled

“Important Information for Medi-Cal Applicants.”

Signature of parent/guardian

Date

According to California Code of Regulations, Title 22, Section 50175, if you fail to return the required information and/or document(s) or if the

information and/or documents you send do not verify your eligibility, your application for Medi-Cal shall be denied or eligibility shall be

discontinued.

MC-368M (06/07)