New York State OutofNetwork Surprise Medical Bill Assignment of Benefits Form. Click on the links below to view and then print the forms.NOTE: Some of the application(s) require additional information. Description: Community Connect Public Benefits Application Assistance program provides assistance with filling out the CalFresh and Medi-Cal applications. Most status changes are easy to manage. Simply complete a Benefit Election Form and return it to your department representative within 60 days. I declare that to the best of my knowledge, the residency, financial, and insurance information provided in this form is true, correct and complete. Problems with downloading forms?