Presumptive Eligibility for Pregnant People Program Application

State of California - Health and Human Services

Department of Health Care Services
Presumptive Eligibility for Pregnant People Program Application

If you need help filling out this form, please ask your provider for help.
APPLICANT INFORMATION
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Social Security Number (optional)
Do You Live in California?*

YesNo
What County Do You Live In?*
Home Address Number and Street*
City*
State*
Zip Code
Mailing Address (if different) Number and Street*
City*
State*
Zip Code*
Phone Number*
Other Phone Number
Email Address*
If experiencing homelessness, check the box and indicate (above) where to send any written correspondence.
What language do you speak best?*
What language do you read best?*
If "Safe at Home" participant, check the box and answer the questions below.
What is your P.O. Box address, if known?*
What is your Safe at Home Participant ID, if known?*
MEDI-CAL
Do you have a Benefits Identification Card (BIC)?*

YesNo
What is the identification number on the card?*
Have you received presumptive eligibility services during this current pregnancy?*

YesNo
FAMILY MEMBERS
Please list all family members below

(Include: your spouse and any children under age 21 living with you)
Name

First NameLast Name
Middle Initial
If expecting multiple births, how many children are you expecting?
Relationship to you
If you need more spaceto answer,please write on the backof this form or a separate sheet of paper and check this box.

YesNo
Total Number of Family Members (including all unborn children in the household)
ANNUAL OR MONTHLY INCOME
Please include money you and/or family members listed on this application receive from jobs, tips, commissions, pensions, Social Security, spousal support, or unemployment benefits.
Please include money you and/or family members listed on this application receive from
Annual Income:
Monthly Income:
SIGNATURE AND DECLARATION
By signing, I declare that what I provided below is true and correct.

• I have read and understand this Presumptive Eligibility for Pregnant People Medi-Cal Application.
• I have received the insurance affordability program application.

• I understand that I must complete and submit the Medi-Cal or insurance affordability application by the end of my Presumptive Eligibility period to be eligible for continued coverage.
• The information I provided is true, correct, and complete.
Signature*

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Date*

MonthDayYear
Signature of Witness*

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Date*

MonthDayYear
PROVIDER USE ONLY
Did the patient self - attest to pregnancy?

YesNo
Was a pregnancy test given today?

YesNo
If a test was given, what was the result?

PositiveNegative
Expected Date of Delivery

MonthDayYear
An individual has a right to review records containing their personal information. The official entity responsible for keeping the information contained in this application is the California Department of Health Care Services and Covered California. This information may be shared with the County Department of Social Services in the county in which the individual resides. The individual’s medical information will be kept with the Presumptive Eligibility for Pregnant People Provider and Covered California.
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State of California - Health and Human Services

Presumptive Eligibility for Pregnant People Program Application

APPLICANT INFORMATION

MEDI-CAL

FAMILY MEMBERS

Please list all family members below

ANNUAL OR MONTHLY INCOME

Please include money you and/or family members listed on this application receive from jobs, tips, commissions, pensions, Social Security, spousal support, or unemployment benefits.

SIGNATURE AND DECLARATION

By signing, I declare that what I provided below is true and correct.

PROVIDER USE ONLY