Fillable Medi-Cal MEDI-CAL REQUEST FOR INFORMATION) (Department of Health Care Services)

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Medi-Cal MEDI-CAL REQUEST FOR INFORMATION) (Department of Health Care Services)

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State of California—Health and Human Services Agency Department of Health Care Services
Medi-Cal Program
Medi-Cal
MEDI-CAL REQUEST FOR INFORMATION)
MC 355 PUN (Rev.07/18)
:
 :
:
 :
 :
 :
:
:
:   
 Medi-Cal  (Eligibility) 
 ,  
 

    Medi-Cal
!

  
 , , , ,  
  
MC 355 PUN (Rev.07/18)
-

     
, ,  
   
 
!
   
(  
Medi-Cal MEDI-CAL REQUEST FOR INFORMATION)
    

 
Medi-CalCovered California, 
 

 ,  , 

 :
  , 
 
  
:
     
 ,  
,  .
-, Schedule C , 
:
MC 355 PUN (Rev.07/18)
— 
:
(, )- 
:
—

:
—  :
 :
" “(Request for Tax Household Information
(RFTHI)” :
:

, , , :
:
Medi-Cal
California:
  :
 :
  ,
. 
MC 355 PUN (Rev.07/18)
   
 ,  .

: 18 '
 
18 .

:

, , 


:
       (,  , )  :
  , , ,         
:
 (United States)
, , 
:
, :

:
, 12  
:
 , Medi-Cal ,
.
 
:
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Completed 30 July 2020

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