Page 1 of 2 Date: Los Angeles County Department of Public Social 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date' at the top of the form. This is essential for tracking your application.
3. Fill in the 'Case Name' and 'Case Number' fields accurately to ensure proper identification of your case.
4. Complete the 'District Name' and 'District Address' sections with relevant information about your local office.
5. Provide details for 'Worker Name', 'Worker File Number', and 'Worker Phone Number' to facilitate communication with your caseworker.
6. Indicate your Medi-Cal status by checking the appropriate box, either ‘No Medi-Cal’, ‘Pending Medi-Cal’, or ‘Pending Plan Selection’.
7. In Section 1, answer whether there is a psychiatric or substance abuse problem that may prevent work by selecting ‘YES’ or ‘NO’.
8. Proceed to Section 2 and check if any presumptive disability conditions apply. If so, answer ‘YES’ and skip to sign at the bottom.

Start using our platform today to complete your form easily and for free!