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Get CA DHCS MC 371 2009-2023

Icant/Caretaker’s Relationship to Child(ren) Name on Birth Certificate Gender Pregnant? q Yes q No Due date: _______________ # of babies_____ Social Security No. Date of Birth q Male q Month Female Day Year Place of Birth (City/State/Country) Medi-Cal Requested? q Yes q No If Yes, provide Benefits Identification Card # if you have it: U.S. Citizen or National? q Yes If No, date arrived in the U.S. Linkage SSN PREG q No Month Case name: Case # Worker # Date: Day Year Does thi.

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