Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (Laotian) - Health And Human Services Agency

State of California – Health and Human Services Agency

Department of Health Care Services

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Medi-Cal

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I declare under penalty of perjury under the laws of the State of California that the information above is true

and correct.

Date:

Signature of eligibility worker

Name of eligibility worker

(print):

First

Middle

Last

Telephone number: