CA CHHS MC 210 2001 free printable template

Print clearly. Use black or blue ink only. Tell us about the person who wants Medi -Cal for themselves, their family or children in their care. SECTION 1. Tell us about the person listed in Section

• Who needs an Application for Medical form?
• What is the Application for Medical for?
• Is the Application for Medical accompanied by other forms?
• • When is Application for Medical form due?
  • How do I fill out Application for Medical form?
  • Where do I send Application for Medical form?

—Your relationship with the person listed in Section 1. —Your name, address and telephone numbers. —The details about any health problems the person has. —Your name and personal contact information. —Tell us about any family history of, or problems associated with, disease or disease condition with which the person may have been affected. —Are there any current or past illnesses with which he or she has had or has developed an association? —Are there any medical problems or illnesses the person has (whether they have been reported to the Health Information and Promotion Commission), including symptoms, laboratory results or past symptoms. —Are there any past problems with a mental or physical health condition which might affect the person (e.g. bipolar disorder, manic depression, schizophrenia, epilepsy). —Has the person been treated for any of these health problems, including, in the case of mental health problems, having been prescribed treatment, or having been taking psychiatric medications: a. Has the person been prescribed treatment for depression (e.g. prescribed psychiatric meds): -Has the person been taking treatment for any substance abuse disorder: b. Has the person been taking medication for an eating disorder (e.g. anorexia, bulimia): -Has the person had any past or current problems with drug taking, alcohol use or drug addiction: -Does the person suffer from any substance abuse or dependence problems (bipolar disorder, manic depression, schizophrenia, etc.): -Have the person's family or children have a history of mental illness (e.g. bipolar disorder, megalomania, pathological gambling) or substance abuse (fails if person's bipolar disorder, mania or a drug problem)? —What are the conditions or conditions which may predispose someone to drug or drug ills? —Is the person in denial about the seriousness of his or her problems (e.g.

Who needs an Application for Medical form?

Any low-income person (or families, seniors, homeless people, persons with disabilities, children in foster care and others) living in California can file a Medical Application to obtain benefits of California Medicaid welfare program.

What is the Application for Medical for?

This Media Cal online application form provides detailed information about the person applying for assistance. Including person’s disability status, information about children of an applicant, person’s income, expenses and insurance information.

Is the Application for Medical accompanied by other forms?

You are not required to accompany the submission of the Media Cal application form with any documents. But further, you have to be ready to provide all necessary documents confirming your low-income status.

When is Application for Medical form due?

Dates for the submission of this form are not set. You can apply for participation in the Medical program at any time.

How do I fill out Application for Medical form?

The applicant must provide personal information about themselves as well as to answer questions on the following topics:

• Family and children;
• Income money for the whole family and in person;
• Expenses/cost paid for the whole family and in person;
• Person’s language and cultural characteristics.

Where do I send Application for Medical form?

Completed and signed application should be directed to Covered California, P.O. Box 989725, West Sacramento, CA 95798-9725.

Instructions and Help about application for medi-cal

People Also Ask about application for medi-cal

How do I contact Medi-Cal?

​ ​​​​(800) 977-2273​ Medi-Cal Rx ​Members and Providers: If you have a question, need help, or need to report a problem, please call (800) 977-2273 for our Medi-Cal Rx Customer Service Center (CSC)​.

How much can I make to qualify for Medi-Cal?

Medi-Cal is the health care insurance program for low-income individuals who live in California. Other states call their program Medicaid. You must financially qualify for Medi-Cal. Most single individuals will qualify for Medi-Cal if there income is under $1,676 per month.

How do I contact Medi-Cal customer service billing?

​​Payment and Billing Questions If you have billing issues or questions, please contact the Medi-Cal Provider Service Center at (800) 541-5555 ​(outside of California, please call (​916) 636-1980).

How do I talk to a real person at Medi-Cal?

Medi-Cal Rx ​Members and Providers: If you have a question, need help, or need to report a problem, please call (800) 977-2273 for our Medi-Cal Rx Customer Service Center (CSC)​.

How long does it take to qualify for Medi-Cal?

The process for verifying your Medi-Cal eligibility, from the time your completed application is received to when you receive your Benefits Identification Card (BIC), normally takes 45 days.

How much a month do you need to qualify for Medi-Cal?

The number you get is the amount of monthly income that is counted for the A & D FPL program. If it is less than $1,677 for individuals or $2,268 for a couple, then you qualify for free, full scope Medi-Cal based on A&D FPL rules.

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