State of California—Health and Human Services Agency Department of Health Care Services
MC 4026 (05/07)
REQUEST FOR ELIGIBILITY LIMITED SERVICES
Name of applicant (last, first) FOR COUNTY USE ONLY–State Number
County Aid Serial Number FBU Person Number
PART A.
I need/continue to need services related to: (Please check one or more of the following.)
Under Age 12 and Older: Age 12 Years and Older:
1.
❒ Sexual Assault 3. ❒ Sexually Transmitted Diseases
2.
❒ Pregnancy or Family Planning 4. ❒ Drug or Alcohol Abuse
5.
❒ Outpatient Mental Health*
* If requesting outpatient mental health services, a statement from a mental health professional confirming that you meet the requirements for those services
must be presented to your eligibility worker.
PART B.
I am requesting medical assistance for the month of:____________/______
Month Year
PART C. RIGHTS AND RESPONSIBILITIES
1. I understand that I will receive a paper Medi-Cal ID card that is good for one year from the issue date
on the card. This card is for identification only and does not verify eligibility.
2. I understand that my eligibility is good for one month, and each month I need Minor Consent medical
services, I must come back into the welfare department to recertify my eligibility to at least one of the
above services. To allow time for my eligibility worker to process my recertification, I must come in and
complete this form as soon as I know I need to see a doctor or need medical care.
3. I understand that if any of the following happens, I must tell my eligibility worker at my next interview
when I recertify my eligibility:
a. I move out of my parent’s/guardian’s house.
b. I get married.
c. My parent(s) stop supporting me or declaring me as a dependent for tax purposes.
d. I get a job or quit working.
e. My income, such as earnings, increases, decreases, or stops.
f. I get some property; i.e., bank accounts, automobiles, stocks, bonds, trust funds, etc.
g. I give birth or my pregnancy ends for any reason.
4. I understand that I will receive this card and the medical services I have requested without my parents
being contacted.
Signature of Applicant Date
Signature of County Representative Worker number Date
