Transcription of Medi-Cal Annual Redetermination Form
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Medi-Cal Annual Redetermination Form
State of California Health and Human Services Agency Department of Health Care Services Medi-Cal Annual Redetermination form . You must fill out this form and return it to the county to keep your Medi-Cal ! Case Number (optional) Social Security Number (optional). Print Your Full Name (if you have not moved, put address label here if one is provided) Birth Date (optional) (mm/dd/yyyy). Current Street Address, Apartment Number (check here if address is new) City/State Zip Code Mailing Address (if different from above) City/State Zip Code Use ink and Print your answers.
State of California—Health and Human Services Agency Department of Health Care Services
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