Medi-Cal Health Benefits

State and Federal Forms

All forms are also available at the Customer Service Centers. The links below will take you to the State of California Dept. of Social Services website.

• Medi-Cal Application - 4 Ways to Apply - To download an application, click the "Choose Language" button, and then select the language you would like to use on your application form.
• MC 13 Statement of Citizenship, Alienage, and Immigration Status (PDF, 864 KB)
• MC 210 PS Property Supplement (PDF, 231 KB)
• MC 220 Authorization for Release of Information (PDF, 67 KB)
• SAWS 1 Application For Cash Aid, CalFresh, and/or Medi-Cal/State CMSP (PDF, 140 KB)

Spanish Translations

• SAWS 1 Application For Cash Aid, CalFresh, and/or Medi-Cal/State CMSP (PDF, 64 KB)

Medi-Cal Information Notices

• U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity (PDF, 36 KB)
• Important Information Regarding Your Appeal Rights (PDF, 474 KB)