Medi cal choice form 2026

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Click ‘Get Form’ to open it in the editor.
Begin by printing the form using a blue or black pen. Ensure that you fill in all sections completely.
Provide information for each household member receiving Medi-Cal. If there are more than three members, contact customer support for an additional form.
For the Head of Household section, enter your first and last name, sex, telephone number, and home address accurately.
In the Applicant sections (1st, 2nd, and 3rd), fill in each applicant's details including their first name, last name, social security number, and health plan preference.
If applicable, indicate if any family member is pregnant and provide the due date.
Complete the reasons for changing Medi-Cal Health Plans if necessary. This helps clarify your choices.
Finally, sign and date the form at the bottom. Ensure all signatures are provided where required before submission.

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