Form Dhcs 0011 - California Proof Of Acceptable Citizenship Or Identity Documents (Chinese) - Health And Human Services Agency
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1State of California – Health and Human Services Agency
Department of Health Care Services
Medi-Cal
•
•
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 fi lls out this box
Case No:
Case Name:
DHCS 0011 (06/08) – Chinese
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