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Phone: 877.633.4435
'Eligibility Happens Here'
Free Medi-Cal Assessment (Single)
Free Medi-Cal Assessment (Married)
Medi-Cal Assessment
For:
Married
Applicants
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.
Medi-Cal Assessment
First Name
Last Name
Email
Street Address
City
Region/State/Province
Postal / Zip code
Phone
Additional Info
Relationship to Appplicant
Would you like Text Notifications
How Did You Hear About Us?
Medi-Cal Applicant
Are You Currently on Medi-Cal?
YES
NO
Medi-Cal Application in Process
Veteran
YES
NO
Surviving Spouse of a Veteran
What do you want to accomplish with Medi-Cal?
Age
Mental Capacity
Good
Fluctuating
No Capacity
Does anyone have Power of Attorney?
If Yes, Who is the Power of Attorney?
Curent Residence (meaning where is resident housed?)
Home
Skilled Nursing Facility
Assisted Living
Board & Care
Hospital
Living with a Family Member
Applicant's Adult Children (how many)
Applicant's Minor Children (how many)
Health Insurance
Health Insurance Monthly Premium Amount
Dental Insurance
Dental Insurance Monthly Premium Amount
Vision Insurance
Vision Insurance Monthly Premium Amount
Life Insurance
YES
NO
Life Insurance Cash Surrender Value Amount
Vehicle(s) (year, make, model)
Do you own a Home?
YES
NO
In the Last 30 Months was Anything:
Transferred
Sold
Gifted
NO
Do you have a Living Trust?
Do you have any Burial Arranged?
Applicant's Assets / Checking Account $
Applicant's Assets / Savings Account $
Applicant's Assets / Retirement Account $
Applicant's Assets / Annuities Account $
Applicant's Assets / IRA Account $
Applicant's Assets / Stocks/Bonds $
Applicant's Assets / Other $
Income (Please list 'source' and 'amount' for each type)
SPOUSE (section) / SPOUSE NAME:
Spouse / Age
Spouse / Mental Capacity
Good
Fluctuating
No Capacity
Current Residence
Home
Skilled Nursing Facility
Assisted Living
Living with Family Member
Hospital
Spouse's Adult Children (how many)
Spouse's Minor Children (how many)
Spouse / Health Insurance
Spouse / Health Insurance Monthly Premium Amount
Spouse / Dental Insurance
Spouse / Dental Insurance Monthly Premium Amount
Spouse / Vision Health Insurance
Spouse / Vision Health Insurance Monthly Premium Amount
Spouse / Life Insurance Cash Surrender Value Amount
Spouse / Vehicle(s) (Year, Make, & Model)
Spouse / Do you Own a Home
YES
NO
Spouse / In last 30 Months was Anything
Transferred
Sold
Gifted
NO
Spouse Assets / Checking Account $
Spouse Assets / Savings Account $
Spouse Assets / Retirement Account $
Spouse Assets / Annuities Account $
Spouse Assets / Stocks/Bonds Account $
Spouse Assets / Other $
Spouse Income (List Source & Amount for each type of income)
Submit Here
