State of California – Health and Human Services Agency Department of Health Care Services
Request for California Birth Record
Medi-Cal can ask for a birth record for people born in California — for free!
Here’s how:
• Fill out this form. Type
or print neatly. You
may use the
information from a
copy of a birth
certificate to complete
this form.
•
Take or mail your
c
ompleted form to
your local social
services office.
• If you have difficulty
filling out this form,
call your local social
services office.
We may not be able to
get the birth record you
are asking for. If this
happens, you must
provide other proof of
citizenship.
If we get the birth record
you are asking for, you
must still provide proof
of identity.
The county social services
office needs the information
requested to search for
a California birth record to
prove citizenship. You do not
have to provide this
information. But if you do not,
the county may not be able to
find the birth record.
Today’s date:
Month: Day:
Year:
Name of person filling out this form:
First: Middle: Last:
Whose birth record do you want?
Name on birth certificate:
First: Middle: Last:
If this person was adopted, write
adopted name:
First: Middle: Last:
Sex:
� Male � Female
Date of birth:
Month: Day:
Year:
City and County of birth:
City: California county:
Mother’s maiden name:
First: Middle: Last:
Father’s name:
First: Middle: Last:
Birth Certificate # (if you know it):
Name of next person whose birth
record you want:
First: Middle: Last
If this person was adopted, write
adopted name:
First: Middle: Last
Sex:
Male Female
Date of birth:
Month: Day:
Year:
City and County of birth:
City: California county:
Mother’s maiden name:
First: Middle: Last:
Father’s name:
First: Middle: Last:
Birth Certificate # (if you know it):
County fills out this box
Case No: Case Name:
If you need more than two birth records, fill out another form.
DHCS 0004 (06/07)
