Medi-Cal Eligibility Division Translated Forms: Spanish

Medi-Cal Eligibility Divisi​on forms are listed below, alphabetically, by form number and has been translated into Spanish

PDF fill and print forms may be completed online and printed to hardcopy to be signed and mailed in or submitted in person to an eligibility worker for processing. 

NOTE: Some links on this page are documents in Adobe Acrobat Portable Document Format (PDF); unless indicated are smaller than 2 MB. PDF documents require Adobe Reader. If you need to install or upgrade to the latest version, click the “Download Free Readers”.

DHCS Forms: Spanish

• DHCS 0001 (07/09) (Sp) - U.S. Citizens and Nationals Applying for Medi-Cal Must Show Proof of Citizenship and Identity
• DHCS 0002 (01/08) (Sp) - Proof of Citizenship and Identity--New Requirements for Medi-Cal Beneficiaries who are U.S. Citizens or Nationals
• DHCS 0003 (06/07) (Sp) - Affidavit of Reasonable Effort to Get Proof of Citizenship
• DHCS 0004 (06/07) (Sp) - Request for California Birth Record
• DHCS 0005 (02/08) (Sp) - Receipt of Citizenship or Identity Documents
• DHCS 0006 (08/07) (Sp) - Proof of Citizenship and Identity
• DHCS 0007 (12/07) (Sp) - Acceptable Citizenship and Identity Documents
• DHCS 0008 (01/08) (Sp) - Proof of Citizenship and Identity Requirements--For Children who are U.S. Citizens or Nationals filling out the Healthy Families/Medi-Cal Joint Application
• DHCS 0009 (09/07) (Sp) - Affidavit of Identity for U.S. Citizen or National Children Under 18
• DHCS 0011 (06/08) (Sp) - Proof of Acceptable Citizenship or Identity Documents
• DHCS 7068 (07/07) (Sp) - Responsibilities of Public Guardians/Conservators or Applicant/Beneficiary Representatives
• DHCS 7077 (01/18) (Sp) - Notice Regarding Standards for Medi-Cal Eligibility
• DHCS 7077 A (07/07) (Eng/Sp) - Notice Regarding Transfer of a Home for Both a Married and an Unmarried Applicant/Beneficiary
• DHCS 7096 (07/07) (Sp) - Department of Developmental Services Waiver Referral
• DHCS 7102 (01/15) (Sp) - Notice Regarding Standards for Medi-Cal Eligibility for Distribution by Insurers, Agents, and Brokers

MC Forms: Spanish 

• MC 0021 (04/07) (Sp) - Medi-Cal to Healthy Families Bridging Consent Form
• MC 14 A (09/11) (Sp) - Qualified Low-Income Medicare Beneficiary, Specified Low-Income Medicare Beneficiary, and Qualifying Individuals Application
• County Listing (Sp) 
• MC 18 (07/07) (Eng/Sp) - Important Notice About Your Medi-Cal Benefits
• MC 174 (05/07) (Eng/Sp) - Medi-Cal Notice to Providers - Clarification of Liability
• MC 176 PA-A (01/09) (Sp) - Medi-Cal Property Assessment Application
• MC 176 PA-1/PA-2 (05/07) (Sp) - Property Worksheet/Assessment for Institutionalized Spouses
• MC 176 S (03/09) (Sp) - Medi-Cal Status Report
• MC 176 TMC (10/08) (Sp) - Transitional Medi-Cal (TMC) Quarterly Status Report
• MC 179 (01/08) (Sp) - Disability Evaluation Form
• MC 209 (05/12) (Sp) - Changes to your Medi-Cal coverage during your pregnancy and after you give birth
• MC 210 A (09/07) (Sp) - Supplement to Statement of Facts for Retroactive Coverage/Restoration
• MC 210 B (08/01) (Sp) - Supplement to Statement of Facts 
• MC 210 PA (05/07) (Sp) - Property Assessment Statement of Facts
• MC 210 PS (05/07) (Sp) - Property Supplement
• MC 210 RV (05/11) (Sp) - Medi-Cal Annual Redetermination
• MC 210 S-C (05/07) (Sp) - Additional Children
• MC 210 S-E (05/07) (Sp) - Student Educational Expenses
• MC 210 S-I - (09/08) (Sp) - Income In-Kind/Housing Verifications 
• MC 210 S-W (07/07) (Sp) - Vocational and Work History
• MC 212 (07/07) (Sp) - Medi-Cal Residency Declaration
• MC 214 (07/07) (Sp) - Important Information About Residency
• MC 215 (10/07) (Sp) - Request for Withdrawal and/or Waiver of Ten-Day Advance Notice
• MC 219 (11/15) (Sp) - Important Information for Persons Requesting Medi-Cal
• MC 220 8pt (06/08) (Sp) - Authorization for Release of Information - 8 point print
• MC 220 14pt (04/08) (Sp) - Authorization for Release of Information - 14 point print
• MC 223 C (06/11) (Sp) - Supplemental Statement of Facts for Medi-Cal Child Applicant Only - Under Age 18
• MC 223 (10/09) (Sp) - Applicant's supplemental statement of facts for Medi-Cal Adult Applicant Only
• MC 239 DRA-6 (02/10) (Sp) - Info Notice - Unable to Verify United States (U.S.) Citizenship/Identity Through The Social Security Administration
• MC 250 A (12/14) (Sp) - Application and Statement of Facts for An individual Who is Over 18 and Under 21 and Who Was in Foster Care Placement on His or Her 18th Birthday
• MC 262 (06/07) (Sp) - Redetermination for Medi-Cal Beneficiaries (Long-Term Care in Own MFBU)
• MC 263 S-R (02/09) (Sp) - Statement of California Residency
• MC 264 (09/11) (Sp) - Presumptive Eligibility for Pregnant Women Program Patient Fact Sheet
• MC 265 (06/07) (Sp) - Patient Directions for Presumptive Eligibility Application
• MC 267 (05/08) (Sp) - Explanation of Ineligibility for Presumptive Eligibility
• MC 273 (05/07) (Sp) - Work Activity Report
• MC 274 TB (05/07) (Sp) - Medi-Cal Tuberculosis Program Application
• MC 306 (01/08) (Sp) - Appointment of Representative
• MC 322 (09/07) (Sp) - Real and Personal Property - Supplement to Medi-Cal Mail-In Application
• MC 330 (07/11) (Sp) - Newborn Referral (Not an Application for Medi-Cal)
• MC 338 Flyer (05/07) (Sp) - Medi-Cal Program for Workers with Disabilities 250 Percent Working Disabled Program
• MC 354 (05/07) (Sp) - Medi-Cal Contact Update
• MC 355 (06/08) (Sp) - Medi-Cal Request for Information
• MC 356 (05/07) (Sp) - "Safe Arms for Newborns" Medical Questionnaire
• MC 368 A (11/10) (Sp) - Important Information for Medi-Cal Applicants
• MC 368 M (06/07) (Sp) - Supplemental Form for Express Enrollment Applicants
• MC 371 (06/09) (Sp) - Additional Family Members Requesting Medi-Cal
• MC 372 (12/21​​) (Sp) - Breast and Cervical Cancer Treatment Program (BCCTP) Flyer
• MC 4026 (07/07) (Sp) - Request for Eligibility Limited Services
• MC 4035 (04/08) (Sp) - Medi-Cal Consent Form

MC Information Notices: Spanish

• MC Information Notice 002 (09/07) (Sp) - Summary Medi-Cal Eligibility (2.18MB)
• MC Information Notice 003 (11/12) (Sp) - Early and Periodic Screening, Diagnosis, and Treatment Services
• MC Information Notice 004 (05/07) (Sp) - Important Information for Medi-Cal Nursing Home Patients
• MC Information Notice 007 (04/13) (Sp) - Medi-Cal General Property Limitations
• MC Information Notice 008 (10/11) (Sp) - Qualified Medicare Beneficiary Program
• MC Information Notice 010 (01/09) (Sp) - Qualified Disabled Working Individual
• MC Information Notice 013 (05/07) (Sp) - Important Information Regarding Your Appeal Rights
• MC Information Notice 017 (07/07) (Sp) - What You Should Know About Your Medi-Cal Disability Application