Form Mc 210 S-C - Additional Children (Ninos Adicionales)
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1
2State of California—Health and Human Services Agency
D epartment of Health Care Services
ADDITIONAL CHILDREN
COUNTY USE ONLY
Case name:
____________________________
(SUPPLEMENT TO THE MEDI-CAL STATEMENT OF FACTS—MC 210)
______________________________________
Case number:
__________________________
Worker number:
_________________________
IF YOU HAVE MORE THAN THREE CHILDREN, LIST HERE AND GIVE THIS FORM TO YOUR WORKER.
Date:
_________________________________
A
Child’s name (first, middle, last) or “unborn”
Relationship to applicant
Citizen/
Linkage
Immig.
SSN
Preg
ID
MC 13
Social Security number
In school
Sex
Male
Female
�
Yes
�
No
�
�
Birthdate or date unborn is due
Is the person blind or disabled
Pregnant
�
Yes
�
No
�
Yes
�
No
�
�
Father’s name
Is either parent (�)
Medical Support
YES
NO
�
�
�
�
�
Deceased
Incapacitated
Absent
Unemployed
CA 2.1
�
Mother’s name
Child living in home
Medi-Cal requested
Not in home, 18–21 and tax dep.?
Yes
No
Yes
No
�
�
�
�
B
Child’s name (first, middle, last) or “unborn”
Relationship to applicant
Citizen/
Linkage
Immig.
SSN
Preg
ID
MC 13
Social Security number
In school
Sex
�
�
�
Male
�
Female
Yes
No
Birthdate or date unborn is due
Is the person blind or disabled
Pregnant
�
�
�
�
Yes
No
Yes
No
�
�
Father’s name
Is either parent (�)
Medical Support
YES
NO
�
�
�
�
�
Deceased
Incapacitated
Absent
Unemployed
CA 2.1
�
Mother’s name
Child living in home
Medi-Cal requested
Not in home, 18–21 and tax dep.?
�
Yes
�
No
�
Yes
�
No
C
Child’s name (first, middle, last) or “unborn”
Relationship to applicant
Citizen/
Linkage
Immig.
SSN
Preg
ID
MC 13
Social Security number
In school
Sex
Male
Female
�
�
�
�
Yes
No
Birthdate or date unborn is due
Is the person blind or disabled
Pregnant
�
�
�
�
Yes
No
Yes
No
�
�
Father’s name
Is either parent (�)
Medical Support
YES
NO
�
�
�
�
�
Deceased
Incapacitated
Absent
Unemployed
CA 2.1
�
Mother’s name
Child living in home
Medi-Cal requested
Not in home, 18–21 and tax dep.?
Yes
No
Yes
No
�
�
�
�
D
Child’s name (first, middle, last) or “unborn”
Relationship to applicant
Citizen/
Linkage
Immig.
SSN
Preg
ID
MC 13
Social Security number
In school
Sex
�
�
�
Male
�
Female
Yes
No
Birthdate or date unborn is due
Is the person blind or disabled
Pregnant
�
�
�
�
Yes
No
Yes
No
�
�
Father’s name
Is either parent (�)
Medical Support
YES
NO
�
�
�
�
�
Deceased
Incapacitated
Absent
Unemployed
CA 2.1
�
Mother’s name
Child living in home
Medi-Cal requested
Not in home, 18–21 and tax dep.?
�
Yes
�
No
�
Yes
�
No
E
Child’s name (first, middle, last) or “unborn”
Relationship to applicant
Citizen/
Linkage
Immig.
SSN
Preg
ID
MC 13
Social Security number
In school
Sex
Male
Female
�
�
�
�
Yes
No
Birthdate or date unborn is due
Is the person blind or disabled
Pregnant
�
�
�
�
Yes
No
Yes
No
�
�
Father’s name
Is either parent (�)
Medical Support
YES
NO
�
�
�
�
�
Deceased
Incapacitated
Absent
Unemployed
CA 2.1
�
Mother’s name
Child living in home
Medi-Cal requested
Not in home, 18–21 and tax dep.?
Yes
No
Yes
No
�
�
�
�
F
Child’s name (first, middle, last) or “unborn”
Relationship to applicant
Citizen/
Linkage
Immig.
SSN
Preg
ID
MC 13
Social Security number
In school
Sex
�
�
�
Male
�
Female
Yes
No
Birthdate or date unborn is due
Is the person blind or disabled
Pregnant
�
�
�
�
Yes
No
Yes
No
�
�
Father’s name
Is either parent (�)
Medical Support
YES
NO
�
�
�
�
�
Deceased
Incapacitated
Absent
Unemployed
CA 2.1
�
Mother’s name
Child living in home
Medi-Cal requested
Not in home, 18–21 and tax dep.?
�
Yes
�
No
�
Yes
�
No
MC 210 S-C (ENG/SP) (05/07)
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