Fillable Proof of Citizenship or Identity Needed (Department of Health Care Services)

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Proof of Citizenship or Identity Needed (Department of Health Care Services)

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State of California – Health and Human Services Agency Department of Health Care Services
Proof of Citizenship or Identity Needed
For Medi-Cal Applicants and Beneficiaries
Who Are U.S. Citizens or Nationals
A new law says most Medi-Cal applicants and beneficiaries who are U.S. citizens or nationals must provide
proof of citizenship and proof of identity. Please provide the information checked below by ______________.
Name of Applicant or Beneficiary
(First – Middle – Last):
This person is exempt or has met the requirements. We do not need any other proof.
Please provide proof of identity for this person.
Please provide proof of citizenship for this person.
Please provide proof of citizenship and proof of identity for this person.
We were not able to find this person’s birth record. If this person was born in California, please fill out the
enclosed Request for California Birth Record form and return it.
Name of Applicant or Beneficiary
(First – Middle – Last):
This person is exempt or has met the requirements. We do not need any other proof.
Please provide proof of identity for this person.
Please provide proof of citizenship for this person.
Please provide proof of citizenship and proof of identity for this person.
We were not able to find this person’s birth record. If this person was born in California, please fill out the
enclosed Request for California Birth Record form and return it.
Name of Applicant or Beneficiary
(First – Middle – Last):
This person is exempt or has met the requirements. We do not need any other proof.
Please provide proof of identity for this person.
Please provide proof of citizenship for this person.
Please provide proof of citizenship and proof of identity for this person.
We were not able to find this person’s birth record. If this person was born in California, please fill out the
enclosed Request for California Birth Record form and return it.
If you do not have the information asked for above, but are trying to get it, please let us know. Contact your
local social services office, or fill out the enclosed Affidavit of Reasonable Effort to Get Proof of Citizenship
form and return it.
County fills out this box
Case No: Case Name:
DHCS 0006 (08/07)
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Proof of Citizenship or Identity Needed (Department of Health Care Services)

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Completed 23 November 2020

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