Application Forms « Health Coverage Unit

If you have access to a printer, you can print and complete forms for your application.

An Application Assistor will need to collect information from these forms to complete your application for health coverage.

If you cannot print these forms, an Application Assistor will have them at your enrollment appointment.

Address Verification	español (6.7 KiB)
Bank Verification Form
Child Support Letter	español (12.1 KiB)
Employer Letter	español (8.5 KiB)
Family Members Requesting Medi-Cal	español (305.3 KiB)
Healthy Kids Birthplace Verification	español (15.0 KiB)
Healthy Kids Declaration	español (25.9 KiB)
Income In-Kind Housing Verification
Patient Financial Status Form Appeal	español (19.7 KiB)
Profit & Loss	español (40.4 KiB)
Rental Income Worksheet	español (10.8 KiB)
Self Affidavit Of Income Letter - Medical	español (9.3 KiB)
Step 1 Appeal	español (31.6 KiB)
Step 2 Appeal	español (28.5 KiB)

Health Coverage Unit