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Go to the assessments only if you Do Not Have Medi-Cal

"Click Below to Access a Free Assessment"

Call Us Today: 877.633.4435

'Eligibility Happens Here'

Free Medi-Cal Assessment (Single)

Free Medi-Cal Assessment (Married)

Medi-Cal Assessment- Married

Please complete the below Medi-Cal Assessment before booking an appointment. You will be Booking a Phone Appointment to discuss your completed Assessment. Please proceed with the assessment only if you do Not currently have Medi-Cal coverage.Assessment Instructions:The first few lines of the assessment is for the contact information of the person filling out the assessment. The remainder of the form is for information on the Medi-Cal Applicant.

Medi-Cal Assessment- Married 2025

First name*

Last name*

Email*

Phone*

Multi-line address

Country/Region

Address

City

Zip / Postal code

Additional info

Relationship with applicant*

Would you like text notifications?*

How did you hear about us?*

What would you like to accomplish with Medi-Cal*

Medi- Cal Application Details

Are both spouses in need of Medi-Cal?

Med-Cal applicant first & last name*

Are you curently on Medi-Cal*

If you answered Yes

What is your SOC?

When is your RE due?

When did you submit application?

Is the applicant a Veteran?*

If you answered Yes

What war did they serve?

How long did they serve?

What Branch

Are you currently receiving any Veterans benefits?

Applicant's age*

Mental Capacity

Applicants' mental capacity *

What health issue does the applicant have?*

Current Residence

Current residence of applicant*

If residing in a facility, please provide name, city, sate and date of Admission

Monthly payment $

If residing in at home, what is the residence address?

Who resides in the applicant's home

If spouse resides in facility, please provide name, city, state, and date of admission.

Monthly payment $

Living Trust & Power of Attorney

Does applicant have a living trust?

Does anyone have Power of Attorney?

Name of Power of Attorney

Single choice

Medical POA

Financial POA

Both

Children and Contact Information

How many adult children does the applicant have?

How many minor children does the applicant have?

Anyone we can contact to help this process?

Health Insurance

Does the applicant have health insurance?*

If Yes, name of insurance

Monthly Premium $*

Does the applicant have dental insurance?*

If Yes, name of insurance

Monthly Premium $*

Does the applicant have vision insurance?*

If Yes, name of insurance

Monthly Premium $*

How many life insurance policies does the applicant have?*

Does the applicant receive interest or dividend income from life insurance?

Home Ownership

Does the applicant own a home?*

If applicant owns a home, who currently lives in the home?

Relationship to occupant

Transfers and Financial Interests

In the Last 30 months, was anything the applicant has a legal interest in:*

Please list what was sold or gifted

Does Applicant have Financial Interest in other Real Property?*

2nd home

Rental property

Rental income

Vacation property

Commercial property

Other

None

I have no knowledge of Applicant’s financial interest in real property, mortgage, rental property, commercial property or any other.

Balances and Income

Applicant's assets: Investment Account balance*

Is Applicant receiving income from an investment account?*

If Yes, Required minimum distributions (Monthly/Annually):

Applicant's assets: Annuities account balance*

Is applicant receiving income from an annuities account?*

If Yes, Required minimum distributions (Monthly/Annually):

Applicant's assets:IRA/401L/ Deferred Compensation account balance*

Is applicant receiving income from these accounts?*

Estimated Income*

Please provide estimated balances for applicant's checking account*

Please provide estimated balances for applicant's savings account*

Please provide estimated balances for applicant's stocks and bonds*

Is Applicant receiving Interest from Stocks/Bonds?*

Yes, monthly

Yes, quarterly

Yes, annually

No

I have no knowledge of applicant's stocks or bonds income.

If Yes, Required minimum distributions (Monthly/Annually):

Any other income producing assets? Please list and indicate the amount $ monthly /Annually*

Is applicant receiving income from Social Security?*

If Yes, what is the amount $ Net/Gross

Is Applicant receiving Income from a Pension?*

If Yes, what is the amount? $ net/gross

Spouse's Section

First Name*

Last Name*

Is Spouse on Medi-Cal?*

If Yes, what is the share of cost?*

Current residence of Spouse:*

If Spouse resides in a facility, please provide name, city & state, and date of admission*

Monthly payment (if any)*

How many Life Insurance policies does the Spouse have?*

Check box if no knowledge of Applicant’s Life Insurance.

Does your Spouse receive Interest or Dividend Income from Life Insurance?*

Is the Spouse a Veteran?*

If Yes, what war did they serve?

How long did they serve?

What Branch?

If Yes: Are you currently receiving any Veterans’ benefits?

Spouse's Age*

Mental Capacity

Spouse's mental capacity*

What health issues does the Spouse have?*

Home Ownership

Does the Spouse own a home?

If Spouse owns a home, who currently lives in the home?*

Occupant's relation to Spouse:

Transfers and Financial Interests

In the last 30 months, was anything the Spouse has a legal interest in:*

Please list what was transferred, sold, or gifted:

Does Spouse have Financial Interest in other Real Property?*

2nd Home

Rental property

Vacation property

Commercial property

Other

None

I have no knowledge of Spouse’s financial interest in real property, mortgage, rental property, commercial property or any other.

Balances and Income

Spouse’s assets: Investment account balance:*

Is Spouse receiving income from an Iivestment account?*

If Yes, required minimum distributions (Monthly/Annually):

Spouse’s Assets: Annuities account balance*

Is Spouse receiving income from an annuities account?*

If Yes, estimated income: Yearly/Monthly

Spouse’s Assets: Assets: IRA/401K/deferred compensation account balance:*

Is Spouse receiving Income from these accounts?*

If Yes, estimated income:

Please provide the estimated balance for Spouse's Checking account*

Please provide the estimated balance for Spouse's Savings account*

Spouses’ Assets: Stocks/Bonds Portfolio Value:*

Is Spouse receiving Interest from Stocks/Bonds?*

If Yes, estimated income:

Spouses’ assets: Any other income producing assets:*

Is Spouse receiving Income from Social Security?*

What is the amount Net/Gross*

Is Spouse receiving a pension?*

What is the amount Net/Gross*

CONTACT

NAME:

PHONE

Email

Subject

Message and or Medi-Cal Questions

Medi-Cal Consulting Services

417 South Sherman Ave.

Corona, CA 92882

Mail: info@medihelper.com

Tel: 877.633.4435

or: 951.789.0065

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