Form MC371 "Additional Family Members Requesting Medical" - California

What Is Form MC371?

This is a legal form that was released by the California Department of Health Care Services - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2009;
  • The latest edition provided by the California Department of Health Care Services;
  • Easy to use and ready to print;
  • Available in Vietnamese;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form MC371 by clicking the link below or browse more documents and templates provided by the California Department of Health Care Services.

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Download Form MC371 "Additional Family Members Requesting Medical" - California

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State of California - Health and Human Services Agency
Department of Health Care Services
Additional Family Members Requesting Medi-Cal
County Use Only
Case name:
Applicant/Caretaker’s Relationship to Child(ren)
Case #
u
Applicant/Caretaker’s Name (First, Middle, Last)
Worker #
Date:
Name on Birth Certificate
Gender
Pregnant?
Yes
No
q
q
Linkage
Due date: _______________ # of babies_____
q
Male
q
Female
SSN
Social Security No.
Date of Birth
Medi-Cal Requested?
q
Yes
q
No
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
PREG
Place of Birth (City/State/Country)
U.S. Citizen or National?
Yes
No
q
q
If No, date arrived in the U.S.
Month
Day
Year
ID
Does this person have a physical, mental, emotional or
Marital Status (check one):
developmental disability?
q
Married
q
Single
q
Widowed
q
Divorced
Other
Yes. Date disability began:
No
q
q
Separated
q
Relationship to Applicant/Caretaker
Linkage
v
Spouse/Other Parent’s Name (First, Middle, Last)
Name on Birth Certificate
Gender
Pregnant?
Yes
No
q
q
SSN
Due date:
# of babies
Male
Female
q
q
Social Security No.
Date of Birth
Medi-Cal Requested?
q
Yes
q
No
PREG
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
Place of Birth (City/State/Country)
U.S. Citizen or National?
Yes
No
q
q
ID
If No, date arrived in the U.S.
Month
Day
Year
Does this person have a physical, mental, emotional
Marital Status (check one):
Other
or developmental disability?
q
Married
q
Single
q
Widowed
q
Divorced
Yes. Date disability began:
No
q
q
q
Separated
Relationship to Applicant/Caretaker
Linkage
w
Child’s Name: (First, Middle, Last) or “Unborn”
Name on Birth Certificate
Gender
Pregnant?
q
Yes
q
No
Due date:
# of babies
Male
Female
q
q
SSN
Social Security No.
Date of Birth
Medi-Cal Requested?
Yes
No
q
q
_____ _____ ______
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
PREG
Place of Birth (City/State/Country)
U.S. Citizen or National?
q
Yes
q
No
If No, date arrived in the U.S.
Month
Day
Year
ID
Child living in home?
Yes
No
Child in school?
Yes
No
q
q
q
q
Medical Support?
Mother’s Name:
Father’s Name:
Yes
No
q
q
CW 2.1 Q
q
Does this child have a physical, mental, emotional or
Is either parent:
CW 2.1
q
developmental disability?
q
Deceased
q
Absent
q
Incapacitated
Not in home, 18-21
q
Yes. Date disability began:
No
q
q
tax dependent
Unemployed
q
MC 371_07/09 (Replaces MC 321 HFP-AP and MC 210S-C)
Page 1 of 2
State of California - Health and Human Services Agency
Department of Health Care Services
Additional Family Members Requesting Medi-Cal
County Use Only
Case name:
Applicant/Caretaker’s Relationship to Child(ren)
Case #
u
Applicant/Caretaker’s Name (First, Middle, Last)
Worker #
Date:
Name on Birth Certificate
Gender
Pregnant?
Yes
No
q
q
Linkage
Due date: _______________ # of babies_____
q
Male
q
Female
SSN
Social Security No.
Date of Birth
Medi-Cal Requested?
q
Yes
q
No
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
PREG
Place of Birth (City/State/Country)
U.S. Citizen or National?
Yes
No
q
q
If No, date arrived in the U.S.
Month
Day
Year
ID
Does this person have a physical, mental, emotional or
Marital Status (check one):
developmental disability?
q
Married
q
Single
q
Widowed
q
Divorced
Other
Yes. Date disability began:
No
q
q
Separated
q
Relationship to Applicant/Caretaker
Linkage
v
Spouse/Other Parent’s Name (First, Middle, Last)
Name on Birth Certificate
Gender
Pregnant?
Yes
No
q
q
SSN
Due date:
# of babies
Male
Female
q
q
Social Security No.
Date of Birth
Medi-Cal Requested?
q
Yes
q
No
PREG
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
Place of Birth (City/State/Country)
U.S. Citizen or National?
Yes
No
q
q
ID
If No, date arrived in the U.S.
Month
Day
Year
Does this person have a physical, mental, emotional
Marital Status (check one):
Other
or developmental disability?
q
Married
q
Single
q
Widowed
q
Divorced
Yes. Date disability began:
No
q
q
q
Separated
Relationship to Applicant/Caretaker
Linkage
w
Child’s Name: (First, Middle, Last) or “Unborn”
Name on Birth Certificate
Gender
Pregnant?
q
Yes
q
No
Due date:
# of babies
Male
Female
q
q
SSN
Social Security No.
Date of Birth
Medi-Cal Requested?
Yes
No
q
q
_____ _____ ______
If Yes, provide Benefits Identification Card # if you have it:
Month
Day
Year
PREG
Place of Birth (City/State/Country)
U.S. Citizen or National?
q
Yes
q
No
If No, date arrived in the U.S.
Month
Day
Year
ID
Child living in home?
Yes
No
Child in school?
Yes
No
q
q
q
q
Medical Support?
Mother’s Name:
Father’s Name:
Yes
No
q
q
CW 2.1 Q
q
Does this child have a physical, mental, emotional or
Is either parent:
CW 2.1
q
developmental disability?
q
Deceased
q
Absent
q
Incapacitated
Not in home, 18-21
q
Yes. Date disability began:
No
q
q
tax dependent
Unemployed
q
MC 371_07/09 (Replaces MC 321 HFP-AP and MC 210S-C)
Page 1 of 2
q DHCS 6155
x
Is anyone currently covered by health/dental insurance or Medicare?
Yes
No
q
q
If so, who?
OHC Code:
DHCS 6268
y
Has anyone filed a lawsuit because of an accident or injury?
Yes
No
q
q
q
MC 210 A
z
Do you or any family member want Medi-Cal to cover medical expenses in the last three months
q
Retroactive Coverage
and wish to apply for Medi-Cal?
q
Yes
q
No
List name(s):
Month(s) of coverage:
Month
Month
Month
1
2
3
CW 5
Have you or any family member ever been in U.S. military service?
Yes
No
q
q
q
If Yes, who? Name(s):
Relationship:
The Medi-Cal program may share your information unless you check the box below:
We will share your child’s application with Healthy Families if your child no longer qualifies for free Medi-Cal in the future. If you
do not want us to share it, check here
q
We will share your child’s application with Healthy Kids or similar county program if your child does not qualify for
full-scope Medi-Cal. If you do not want us to share it, check here
q
Family Income: List the income of every person listed in this application. Include child support and spousal support received.
(Use a separate line for each source of income.)
Name of person with Income
Source of Income
How often is income
How much is
Social Security No.
received?
the income?
(Children who are in school do not have to list
(Job, social security,
(Optional)
their income from a job.)
pension, etc.)
(Weekly, biweekly, monthly)
(Total gross
income)
$
$
$
$
$
Expenses: List the monthly expenses for all persons listed above.
Child Day Care or Disabled Dependent Care
For (child or dependent’s name): __________________________________________ Age: ______ Amount Paid: _____________
How Often? ______________
For (child or dependent’s name): __________________________________________ Age: _______ Amount Paid: ____________
How Often? _____________
Court-ordered child support
Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________
Court-ordered spousal support
Paid to: ________________________________ Paid by: _________________________________ Amount paid:_____________
Please note that additional information about your property, income and/or resources may be required if applicable.
I certify that I have read and understand the information above. I also certify that the information I have given on this form is true and
correct.
Signature _____________________________________________________________________ Date: ________________
Page 2 of 2
MC 371_07/09 (Replaces MC 321 HFP-AP and MC 210S-C)
Page of 2