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Get CA Medi-Cal Choice Form

Completely: 3. Fill in all information for each person in your household who gets Medi-Cal. 4. If you have more than 3 family members, call 1-800-430-4263 to ask for another form. Head of Household Sex: __________________________________ Ç First Name Male Female ________________________________________ ( ___ ___ ___ )–___ ___ ___– ___ ___ ___ ___ Ç Last Name __________________________________________________________ Ç Area Code Ç Telephone or Cell Phone Number.

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