State of California—Health and Human Services Agency Department of Health Care Services
MEDI-CAL TO HEALTHY FAMILIES TRANSMITTAL
County name
County representative
Telephone number
Date referred
Case name (last) (first) Case number Applicant name (last) (first)
Language Applicant phone number
Spoken: _________________________ Written:
Healthy Families
P.O. Box 138005
Sacramento, CA 95813-9984
One or more individuals (check all applicable boxes): Type of application (check all applicable boxes):
Changed mind about not wanting Healthy Families
Food stamps only application
❒ Were determined ineligible for Medi-Cal (see comments) ❒ School lunch application
Were determined to have a share-of-cost (see below) Redetermination (RV)
HF
LIST ALL HOUSEHOLD MEMBERS
Individual Type of
Requested M/C FBU CIN Social Security Sex Relationship to Gross Income Share-of-
Yes No Yes No Last Name First Name Number Number Male Female Date of Birth Applicant Income (UIB, SDI)
ENCLOSURES: the following documents are enclosed with the application (check all applicable boxes).
Mandatory:
Medi-Cal NOA(s) and Medi-Cal Budgets (if not on NOA) If available: Birth certificate Immigration Residency
______________________________________________
Copy of appropriate application Other
Comments: Explain why county is forwarding the application. If a member of the household is on CalWORKS, SSI, or Foster Care, please indicate person(s) and type(s)
of assistance.
MC 363 (05/07)
