Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents - Health And Human Services Agency
ADVERTISEMENT
1State of California – Health and Human Services Agency
Department of Health Care Services
Proof of Acceptable Citizenship or Identity Documents
A new law says that most Medi-Cal applicants and beneficiaries who are U.S. citizens or nationals must
provide proof of citizenship and identity.
The county has received and reviewed the proof of citizenship and/or identity that you submitted for:
Applicant or Beneficiary Name:_____________________________________________________________
First
Middle
Last
Date of birth:__________________________
Name of the citizenship document you saw:
Name of the identity document you saw:
Approved. The citizenship document you
Approved. The identity document you submitted
submitted is acceptable proof of citizenship. You
is acceptable proof of identity. You will not have
will not have to provide proof again for the above
to provide the proof again for the above person.
person.
Denied. The proof you submitted is not
Denied. The identity document you submitted is
acceptable. You must submit another proof of
not acceptable. You must submit another proof
citizenship. Attached is a list of acceptable proof
of identity. Attached is a list of acceptable proof
of citizenship documents.
of identity documents.
•
•
All documents must be originals or copies
All documents must be originals or copies
certified by the issuing agency.
certified by the issuing agency.
Photocopies are not acceptable.
Photocopies are not acceptable.
The above person has satisfied the new citizenship and identity requirements because both citizenship and
identity documents were approved.
The above person has not satisfied the new citizenship and identity requirements because one or both of
the citizenship and/or identity documents were denied or not submitted.
If you have questions, please contact your county social services office at the telephone number listed below.
I declare under penalty of perjury under the laws of the State of California that the information above is true
and correct.
____________________________________________________
Date:_________________________
Signature of eligibility worker
Name of eligibility worker
______________________________________________________________
(print):
First
Middle
Last
Telephone number: ____________________________________
County:________________________
County fills out this box
Case No:
Case Name:
DHCS 0011 (06/08)
Page 1 of 1
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (spanish) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (hmong) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (arabic) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (armenian) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (chinese) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (korean) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (laotian) - Health And Human Services Agency
Legal
Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (russian) - Health And Human Services Agency
Legal
Related Categories
Parent category: Legal