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Click ‘Get Form’ to open the facts medi cal applicant form in the editor.
Begin with Part 1—Personal Information. Fill in the child's name, social security number, date of birth, and other personal details clearly. Ensure accuracy as this information is crucial for processing.
Move to Part 2—The Child’s Illnesses, Injuries, or Medical Conditions. Provide detailed descriptions of any medical issues along with their onset dates.
In Part 3—Social Security/SSI Information, indicate if the child has applied for benefits and provide relevant dates and statuses.
Continue to Part 4—Special Sources and School Information. List any agencies that have evaluated the child and provide their contact details.
Complete Parts 5 through 9 by detailing medical visits, medications, tests, work history, and any additional remarks as necessary.
Finally, sign in Part 10—Signature and Certification. Ensure all required signatures are included before submission.

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