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Medi-Cal Assessment
For: Single Applicants

Please complete the Medi-Cal Assessment form below before booking a Phone Appointment to discuss this completed Assessment. Please proceed with the assessment only if the Applicant does Not currently have Medi-Cal coverage.

Assessment Instructions:
The first lines of the Assessment are for the contact information of the person filling out the Assessment. The remainder of the form is for information on the Medi-Cal Applicant. An asterisk * means a section is required.

Medi-Cal Assessment
 
Applicant Information
Is the Applicant currently on Medi-Cal?
Is the Applicant a Veteran?
Applicant's Mental Capacity
Current Residence of Applicant
Does Applicant have Life Insurance?
Does Applicant own a Home?
In the Last 30 Months, was anything the Applicant had a legal interest in:
Does Applicant own a Financial Interest in Other Real Property? *
Please Provide the Estimated Balances for the Following:
After clicking on Submit, please WAIT for the Booking Screen (page) to appear here. 

Book your appointment at that time.

Thank you for completing this Assessment and we look forward to assisting you.
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