Application For Medi-Cal / Covered California

A Government Certified Specialist Will Call You Within 2 Business Days To Assist With Your Application For Enrollment.

* Denotes mandatory field. Please complete all required fields.

Section 1 :

Tell us about the person(s) who want Medi-Cal / Covered California for themselves, their family or children in their care.

Last Name(*) First Name(*) Middle Name
Home Address (number & street). Do not list PO Box unless homeless. Apartment Number Home Phone#(*)
City State Zip Code Work Phone #
County    
   
Email Address    
   
Mailing Address (If different from above) or P.O Box Apartment Number Cell Phone #(*)
City Zip Code
What language do you speak best? What language do you read best?

 

Section 2 :

Tell us about the person listed in section 1, his or her family and the children they care for, even if they don't want coverage.

  Adult1/Self Adult2 Adult3 Child1 Child2 Child3 Child4 Child5
Last Name
First Name
Middle Name
Relationship to person in
section 1
Gender Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Male
Female
Date of Birth:
Marital Status Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed
Single
Married
Divorced
Separated
Widowed

Section 3

List all income/money received by person listed in Section 2.

Name Of The Person Receiving Income/Money Source Of Income / Money Received (Employment, Social Security) Home Much Income / Money Is Received How Income Money Is Received
(Weekly, Every Two Weeks, Bi-Weekly, Monthly)

 

Section 4

Answer only for persons who want Covered California or Medi-Cal Insurance

  Adult1/Self Adult2 Adult3 Child1 Child2 Child3 Child4 Child5
Name
Social Security #
Place of Birth
(State and Country)
U.S. Citizen or Legal Immigration Status In USA? Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Had medical expenses within the 3 months before this application? Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
In school full time? Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No