Get Printable Medi Cal Application

This guide provides clear instructions on how to navigate and complete the Printable Medi Cal Application online. Each section of the application is broken down to ensure that users can easily understand and accurately fill out their information.

Follow the steps to complete the application successfully:

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin with the personal information section, filling in your full name, current address, home address, and phone number. Ensure that all information is accurate to avoid delays in processing.
3. Indicate your race, sex, and ethnicity as applicable. Completing this section is optional for those not requesting assistance but helps in demographic tracking.
4. Provide your birthdate and marital status. Make sure these details are correct to ensure compliance with eligibility criteria.
5. Answer questions about your South Dakota residency and past assistance requests, noting the relevant county if applicable.
6. Provide your Social Security Number and any other relevant identifiers, such as Medicare claim numbers, if you have them.
7. If applicable, proceed to fill out the section regarding your spouse's information. Include their full name, birthdate, and social security number.
8. If you have dependent children, be sure to list their names, dates of birth, and income to assist with your application.
9. Detail your living arrangements and any shelter costs. Break down your expenses by type and amount, providing adequate verification where required.
10. Fill out the medical section, including information about your primary physician, any hospitalizations, and whether you are requesting retroactive assistance.
11. If completed by an authorized representative, provide their information. Include a contact person for additional information if necessary.
12. Address the resources/assets section carefully, listing all relevant financial information. Be thorough in reporting cash, accounts, properties, and insurance.
13. Answer all questions about properties, health insurance, and income sources honestly, as these will be verified.
14. Finally, certify your citizenship or alien status, providing necessary documentation as needed. Sign the application and ensure all required witnesses are present.
15. Once the form is completely filled out, review for accuracy, save changes, and download or print your copy for submission.

Complete your Printable Medi Cal Application online today to ensure you receive the assistance you may be eligible for.