Download California Medi-Cal Application Form | PDF

Download the California Medi-Cal Application Form to apply for health care insurance services in the state of California. This application is available to individuals and families so that they may receive medical coverage at free or very affordable rates. The application is available in a variety of languages to accommodate those from around the world who are in the United States, yet still not fluent in the English language. There will be an opportunity to choose the language of choice once you begin the process.

How To Write

Step 1 – Read the cover pages 1. and 2. The information provided on these pages will provide an idea of what is available and what to expect. It also provides direct contact information if needed and additional information for the deaf who may require assistance.

Step 2 – Section 1. – Start Application Here- Tell us about the adult who will be our main contact for this application – Complete the following:

First Name, Middle Name, Last Name ( Include Suffix Jr., Sr. I, II, III etc.)
Home Address (street address)
Apartment Number (if any)
City
State
Zip Code
County
Check the next box if you have no home address – you must provide a mailing address.
Check the next box if your mailing address is the same as your home address – if your mailing address is not the same, provide your mailing address in the following block.
Mailing address or PO box, if your address is different than your home address.
Apartment Number
City
State
Zip Code
County
Provide the best phone number for which you may be contacted and check the appropriate box.
Provide any other phone number in which you would be able to be contacted – check the appropriate box
Enter the language you would like to be used when writing to you
Enter the language you would like to be spoken to in
Check the appropriate box, for you, as to how you would like to receive information as your application is being process. Include an e mail address in applicable

Step 2 – Section 1. – Are you applying for a child less than one year old?

As stated on this application: Infants less than one year old are eligible for Medi-Cal if their mother was on Medi-Cal or AIM at the time of delivery. You do not need to fill out an application to get Medi-Cal for an infant born to a mother with Medi-Cal or AIM at the time of delivery. Call your county social services office when your baby is born to make sure your baby is covered. Or fill out the information next on the application.
This section is optional – If the following information on this application (below this statement) is provided, the infant may be automatically eligible for Medi-Cal. You do not have to fill out step 2 for the infant. Complete the following:
Are you applying for a child less that one year old? (check yes or no)
If yes, did the child’s mother have Medi-Cal or AIM when the child was born? (check yes or no)
If yes, will the child’s mother be listed on this application? (check yes or no)
If yes, the mother is person # (complete the blank line in this question) – on this application?
If no, what is the mother’s First and Last name? (Place name on the line at the end of this question)
Please provide the mother’s Medi-Cal number, AIM number or Social Security Number (on the blank line at the end of this request)

Step 3 – Tell Us About Your Family – Read the information at the top before you continue to complete the next step in this application process.

Person 1 – Tell Us About Yourself – Complete the following

First Name
Middle Name
Last Name
(include suffixes jr., sr. I, II, III etc.)
Are you male/female- (check the appropriate box)
With regard to marital status: Are you? (check the appropriate box)
Date of birth (mm/dd/yyyy format)
Are you pregnant? If so… (check all appropriate boxes and complete written information in this block
Applying For Health Insurance: (Even if you already have health coverage, you may find that this particular coverage is much more affordable) Complete the following by checking the boxes:
Are you applying for health insurance for yourself?
Check the box next to what would best describe your situation
Provide your social security number
If you have no Social Security Number, check the box that best describes why.

Read the following requirements:

You must provide a Social Security number (SSN) if you wish to apply for health insurance. We use Social Security numbers (SSNs) to check income and other information. Even if you are not applying, giving your SSN will help us review your application faster. Be sure to provide your SSN if you are not applying for yourself but you file taxes and are applying for someone in your tax household. If someone who is applying does not have an SSN and would like help getting one, call 1-800-300-1506 (TTY: 1-888-889-4500) or visit CoveredCA.com

Step 4 – Section 1 – Step 2 – Person 1 – Federal Income Tax Information. If you don’t file taxes, you may still qualify for free or low-cost insurance through Medi-Cal. Your information will be kept private. Your information will only be used to determine whether or not you qualify for Medi-Cal.

Are you going to file taxes for the benefit year? (check the yes or no box)
If yes, how will you file? (check the appropriate box)
Does anyone claim you as a dependent on your taxes? (check yes or no)
If yes, who? (check the box that applies)
Do you have other health insurance or are you offered insurance through a job? (check yes or no)
If yes – fill in Attachment B on Pages 22 and 23
Do you have a physical, mental, emotional, or developmental disability? ( If yes – See FAQ #27 for more information on what it means to have a disability)
Are you a U.S. citizen or U.S. national? (check yes or no)
If you aren’t a US Citizen you must answer the following:
Do you have satisfactory immigration status?(if so, check the yes box)
If you are unsure, and you need to know if you have satisfactory status, go to Attachment E on page 27 for a list. Then write the document information here. In most cases your document ID number will be your Alien Registration Number.
Document Type (what sort of document do you have to prove you have the proper status in the US)
ID Number
Country of Issuance (where were your documents issued – what country)
What would be the expiration date of said documents?
Name as it appears on the document
Have you lived in the US since 1996? (check yes or no)
Are you, your spouse, or an unmarried dependent child an honorably discharged veteran or active-duty member of the U.S. armed forces?(check yes or no)
Do you receive Medicare benefits?(check yes or no)
Did you have any medical expenses in the last 3 months that you need help paying for? (check yes or no)
Do you live with any children under the age of 19? (check yes or no)
If yes, do you take care of the child or children? (check yes or no)
Are you 18 to 20 years old and a full-time student?(check yes or no)
Are you 18 to 26 years old?(check yes or no)
If yes, were you in foster care in any state on your 18th birthday?(check yes or no)
Are you 18 years old or younger? (check yes or no) – If yes, how many parents live with you? (enter the number of parents who live with you on the line)
Are you temporarily living out of state?(check yes or no)
If you would like to choose a health insurance plan now, (Check the box in this sentence), then complete attachment D on page 25.
Tell us about this person’s race ( please note : this information as you will find in writing on this page) is completely confidential and will not be used to decide what sort of coverage you would be eligible for)
What is this person’s race (this section is optional – should you choose to complete it – check All of the boxes that apply)
Is this person of Hispanic, Latino, or Spanish origin? (check yes or no ) – If yes, check in which Hispanic category you belong
Check the box next to the blue star on the left if this person is an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.

Step 5 – Section 1 – Person 2 – Tell us about this person’s current job and how he or she gets money – Complete all following questions by checking the appropriate boxes:

JOB 1: How does this person get paid? – (check all that apply)
JOB 2: How does this person get paid?- (check all that apply)
Is this person self employed -(check the boxes that apply and respond according to the instruction next to your selection)
JOB 1: Is this person self-employed?
Type of work : (check all that apply and fill in the lines next to this block)
JOB 2: Is this person self-employed?
Type of work : (check all that apply and fill in the lines next to this block)
Does this person have other income?
Other income is money you get from something other than your job. Go to Attachment E on page 27 to see examples of other income. Don’t include child support payments, veteran’s payments, or Supplemental Security Income (SSI)
Does this person’s income change from month to month?
(If this person’s income does change from month to month, answer the two question following this one)
Does this person have deductions?
(If so, explaining the deductions could lower the amount paid for coverage, if the answer is yes, answer the two questions below by checking all that apply)

Step 6 – Tell us about the next person living in your home – Person 3 – Provide all applicable information and check all appropriate boxes as follows:

First Name
Middle Name
Last Name
(include suffixes, jr., sr., I, II, III etc.)
Home address (Street and apartment number)
City
State
Zip
County
Check the box to the left if this person does not have a home address. A mailing address must be provided.
Check the box to the left if this person’s mailing address is the same as the main contacts mailing address. If it is not the same, a mailing address must be provided.
Mailing address or PO Box ( if it’s different from the home address)
City
State
Zip
County
Best phone number to reach this person – (check the appropriate box and place the phone number on the line)
Other phone number – (check the appropriate box and place the phone number on the line)
Email Address (write on the line)
What language should we write to this person in?
What language does this person want us to speak to him/her in?
Is this person male or female? – (check the box that applies)
Marital Status – Is this person? … (check the box that applies)
Date of Birth (mm/dd/yyyy format)
Is this person pregnant?
If so, how many babies are expected? (place the number of babies on the line)
What is the expected delivery date? (place the estimated delivery date on the line next to this question)

Applying for Health Insurance – Person 3 – ( Even if this person has insurance now, you might find better coverage or lower costs)

Is this person applying for health insurance? (check one of the boxes and follow the instruction according to selection)
Social Security Number
If this person does not have a social security number, what is the reason? (check any box that applies)

Federal Income Tax Information – Person 3 (If this person didn’t file taxes, he or she can still qualify for free or low-cost insurance through Medi-Cal. We will keep the information private and use it only to decide if the person qualifies for health insurance)

Is this person the primary tax filer (was his or her name the first on the tax form? check yes or no)
Is this person going to file taxes for the benefit year? (check yes or no – if yes – check the box that would reflect this person’s filing status)
Does anyone claim this person as a dependent on his/her taxes? (check yes or no) – If yes (check the box that applies)
Person 3 – Does this person have other health insurance or is this person offered insurance through a job? (check yes or no) – If yes, fill out Attachment B on pages 22 and 23
Does this person need help with long-term care or home and community-based services?(check yes or no)
Is this person a U.S. citizen or U.S. national? (check yes or no) – If this person is not a U.S. citizen or U.S. national, answer all of the questions following this one by checking a box or writing in information)
Does this person receive Medicare benefits?(check yes or no)
Did this person have a medical expense in the last 3 months that he or she needs help paying for?(check yes or no)
Does this person live with any children under the age of 19? (check yes or no)
If yes, does this person take care of the child or children in the home? (check yes or no)
Is this person 18 to 20 years old and a full-time student? (check yes or no)
Is this person 18 to 26 years old? (check yes or no)
If yes, was this person in foster care in any state on his or her 18th birthday? (check yes or no)
Is this person 18 years old or younger? (check yes or no)
How many parents live with this person? (provide the number of parents in the home on the line)
Is this person temporarily living out of state? (check yes or no)
Tell us about this person’s race – (This information is confidential and will only be used to make sure that everyone has the same access to health care. It will not be used to decide what health insurance program this person qualifies for) – (optional, check all of the boxes that apply)
Is this person of Hispanic, Latino, or Spanish origin? (optional, check the box that’s applicable)
Tell us about this person’s current job and how he or she gets money (Attach an extra page if you need more space)
Does this person work now? (check yes or no and follow the instructions next to your selection)
JOB 1: How does this person get paid? (complete the information in the block to the right)
Employer Name (optional, if you choose to reveal this information place the name in the block)
JOB 2: How does this person get paid? (complete the information in the block to the right)
Employer Name (optional, if you choose to reveal this information place the name in the block)
How much does this person get paid (before taxes)? – (place the number on the line to the right)
Is this person self-employed?

Where does this person work or get money?
Type of work (answer the questions to the right)
Does this person have other income? ( Other income is money you get from something other than your job. Go to Attachment E on page 27 to see examples of other income. Do not include child support payments, veteran’s payments, or Supplemental Security Income (SSI) (check yes or no and follow the instructions next to your selection
Where does this person’s income come from? (check the boxes to the right that are applicable)
Does this person’s income change from month to month? If yes, answer the next two questions)
Does this person have deductions? (If this person pays for certain things that can be deducted on a federal income tax return, telling us about them may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions.
Type of deduction-(check boxes that apply)
How often does this person get or pay for this deduction? (check one)

Step 7- Section 1 – Person 4- Tell us about the next person living in your home. Answer all information required with regard to Person 4 living in your home:

Does this person have other health insurance or is this person offered insurance through a job?(check yes or no) – ( If yes, complete Attachment B on pages 22 and 23)
Does this person have a physical, mental, emotional, or developmental disability? (check yes or no) – ( See FAQ #27 for more information on what it means to have a disability)
Does this person need help with long-term care or home and community-based services?(check yes or no)
Is this person a U.S. citizen or U.S. national?(check yes or no)
Does this person have satisfactory immigration status?(To see if this person has satisfactory status, go to Attachment E on page 27 before checking yes on this form)- for a list, Then write the document information here. In most cases the document ID number will be the Alien Registration Number – Complete the other lines as well:
Document Type
ID Number
Country of Issuance
Expiration Date
Name as it appears on the document
Has this person lived in the U.S. since 1996?(check yes or no)
Is this person, this person’s spouse, or an unmarried dependent child an honorably discharged veteran or active-duty member of the U.S. armed forces?
Does this person receive Medicare benefits?(check yes or no)
Did this person have a medical expense in the last 3 months that he or she needs help paying for? (check yes or no)
Does this person live with any children under the age of 19? (check yes or no)
If yes, does this person take care of the child or children? (check yes or no)
Is this person 18 to 20 years old and a full-time student?(check yes or no)
Is this person 18 to 26 years old? (check yes or no) –
If yes, was this person in foster care in any state on his or her 18th birthday? (check yes or no)
Is this person 18 years old or younger? (check yes or no)
How many parents live with this person? (write the number of parents living with this person)
Is this person temporarily living out of state?(check yes or no)
Tell us about this person’s race(This information is confidential and will only be used to make sure that everyone has the same access to health care. It will not be used to decide what health insurance program this person qualifies for) This section is optional – check all that apply)
Is this person of Hispanic, Latino, or Spanish origin? (optional) – (If yes, check the ones that apply)
Check here if this person is an American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21 (check the box to the left, next to the blue star if this applies)
Is this person self-employed? (check yes or no and follow the instructions next to your selection)
JOB 1 – Type of work (complete the block to the right)
JOB 2 – Is this person self-employed?( complete the information in the block to the right)
Does this person have other income?(Other income is money you get from something other than your job. Go to Attachment E on page 27 to see examples of other income. Do not include child support payments, veteran’s payments, or Supplemental Security Income (SSI) – (check yes or no and follow the instructions next to your selection)
Where does this income come from (check all applicable boxes to the right for each job or source)
Does this person’s income change from month to month? If it does, answer the two questions below (check yes or no and follow the instructions next to your selection)
What does this person expect this person’s total income to be this year? (optional) – write the number in the line to the right.
If you expect this person’s income to change next year, what will the new total income be? (optional)- write the number in the line to the right
Does this person have deductions?(If this person pays for certain things that can be deducted on a federal income tax return, telling us about them may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 27 lists other types of deductions) – (check yes or no and follow instructions next to your selection)
Type of deduction (check the appropriate boxes in this column for each job)
How often does this person get or pay for this deduction? (check one for each job)

Step 8 – Please read and sign this application. There are several pages that must be read, understood and signed. If you feel you are reading information that you do not understand, get help understanding what you are signing as you will be completely responsible for whatever you sign.

You may choose an authorized representative to assist you, so that you will be sure about what you are signing. An authorized representative is a person you allow to see your application and talk with the agency about now and in the future as well.
This form is where you will provide your authorized representative, should you decide you would like to have one. Fill out their Name, address information (fill in the lines) – You must sign this if you agree to have this person assist with your information. If you do not wish to have an “authorized representative, please disregard or place “n/a” on the lines.

Step 9 – Read the privacy statement. This protects your rights to privacy and reveals what can legally be released by the agency.

Step 10 – Your Rights and Responsibilities – Read all of the information on this page. It also continues to the next page. Read all of the information provided here to be certain that you understand your rights and responsibilities.

Step 11 – Declaration and Signature – This is Required –

Carefully read this page prior to signing. It’s important that you understand and are declaring that you are providing proper information.
Once you have read the information in this section, you or your authorized representative are required to sign and date the form in the signature and date (mm/dd/yyyy format) blocks

Step 12 – The next form will only be used if you have someone assisting you in completing these pages. If so, that person must complete the information on the page and sign and date the blocks at the bottom.

Step 13- Mailing Information and Checklist-

Read through the check list to be certain you have provided all of the information necessary to prevent delays.

Step 14- The next several pages will only be necessary to complete (some are optional) if they apply to you and/or your family. Here is a listing of the following forms:

Complete the next section if you are a Covered California certified individual helping someone fill out this application.
How did you hear about Covered California? (check any that apply)
Do you need more information on other California Programs? If so check those you would like more information about after reading through the page to know what is available.
For American Indians and/or Alaskan Natives- You may be able to save out of pocket costs for some of the insurance services. American Indians may receive services from Indian Health Services. You may also get special enrollment periods. If you’re interested, complete and sign this form.
Tell Us About Your Family’s Health Insurance – Most important with this form is there is some information that is needed, some is optional. Read the form and provide needed information. With regard to each person living in the home and for whom you have applied.
Employer Insurance Form- This is only necessary for those who qualify for health insurance through their employer.

Step 15 –Choose your pediatric dental plan and your health insurance plan- Important* If you need to tell us about more than four people who would like to choose a pediatric dental plan or health insurance plan, make a copy of this page and the next page, and be sure to send them with your application.

Agreement for Binding Arbitration – Each person on this application must read and sign it. It must be an attachment with your other documents.
The remaining pages are specifically provided to assist you with answers to questions, direct you to proper telephone numbers should you require assistance and more, to include telephone numbers to reach someone who speaks your native language.

Step 16 – Once all of the information is complete, check to make certain you have everything that needs to be included before mailing. Mail your forms for processing.

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