top of page

Medi-Cal Assessment- Single

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- Single

Multi-line address
Would you like text notifications?

Medi- Cal Application Details

Are you curently on Medi-Cal

If you answered Yes

Is the applicant a Veteran?

If you answered Yes

Are you currently receiving any Veterans benefits?

Mental Capacity

Applicants' mental capacity

Current Residence

Current residence of applicant

Living Trust & Power of Attorney

Does applicant have a living trust?
Does anyone have Power of Attorney?
Single choice
Medical POA
Financial POA
Both

Children and Contact Information

Health Insurance

Does the applicant have health insurance?
Does the applicant have dental insurance?
Does the applicant have vision insurance?
Does the applicant receive interest or dividend income from life insurance?

Home Ownership

Does the applicant own a home?

Transfers and Financial Interests

In the Last 30 months, was anything the applicant has a legal interest in:
Does Applicant have Financial Interest in other Real Property?

Balances and Income

Is Applicant receiving income from an investment account?
Is applicant receiving income from an annuities account?
Is applicant receiving income from these accounts?
Is Applicant receiving Interest from Stocks/Bonds?
Is applicant receiving income from Social Security?
Is Applicant receiving Income from a Pension?
bottom of page