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Free Medi-Cal Benefits Assessment for Seniors*

If you are disabled and 65 years or older please complete
the following form to receive your free Assessment.

*If you are less then 65 years old and not disabled please
visit our non seniors page for Medi-Cal resources.


Medi-Cal Assessment for Disabled Seniors
required fields
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Name of Medi-Cal Applicant:

Age:

Is the Applicant Disabled:
Yes     No
If Yes, Please Describe Disability:

Name of Person Submitting Request
(on behalf of applicant):

Email:

Phone:

Other Phone: