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Get Statement Facts Medi Cal 2011-2024

Read ALL of the information below BEFORE you start. If you have any questions about this form, or if you need help filling it out, please call your county social services agency. The information that you provide on this form will be used by the California Department of Social Services, Disability Determination Service Division. That agency will make the disability decision on the child’s Medi-Cal application. To help process the child’s case faster, fill out as much of this form as you can. .

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