Do you know which county?
APPLICATION AND STATEMENT OF FACTS
FOR
AN INDIVIDUAL WHO IS OVER 18 AND UNDER 26 AND WHO WAS IN
FOSTER CARE PLACEMENT ON HIS OR HER 18TH BIRTHD
A
Y
New application
Redetermination
Request for retroactive coverage for months
(Eligibility cannot be established prior to 10/01/00.)
COUNTY USE ONL
Y
Case name:
Case number:
Date
of
discontinuance:
Name Date of birth (mm/dd/yy) Gender
Male Female
Telephone number Social security number
Address (number, street) City State ZIP code
Mailing address (if different) (number, street, P.O. Box) City State ZIP code
Name of state where you were in foster care (e.g. California)
I declare under penalty of perjury under the laws of the State of California that the answers I have given in this
application are true and correct to the best of my knowledge and belief.
Signature Date
Instructions
If you are completing this application it is because you were in foster care when you turned 18. The
Affordable Care Act allows you to receive Medi-Cal benefits at no share-of-cost until you reach the age of 26.
Under this act, you are not required to show proof of income or resources (such as a car) in order to be eligible
for Medi-Cal. You only have to have been in foster care when you turned 18 and have not yet reached 26.
Once you have completed this form, you will have to mail it to or drop it off at your local county social services
department. Check your phone book for the nearest office.
If you move, you will still be eligible for Medi-Cal, but you will have to notify your county eligibility worker of your
address change. If you move out of the county that you lived in when you applied, the county worker will have
to change the information on your case so that you can continue to get medical coverage without difficulty. If
you have any changes in your living arrangements, such as moving back in with your parents or getting
married, or if you are pregnant, notify your eligibility worker immediately to report the change. These changes,
however, will not affect your eligibility for this program.
If you move out of state, you may still be eligible for medical benefits in your new state, but you will have to
apply for these benefits in the new state of residence.
MC 250 A (Rev 01/14)
