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Form Dhcs 0001 - California U.s. Citizens And Nationals Applying For Medi-Cal Must Show Proof Of Citizenship And Identity (Laotian) - Health And Human Services Agency Page 4

State of California – Health and Human Services Agency

Department of Health Care Services

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DHCS 0001 (01/08) – Laotian

Page 4 of 4

Form Dhcs 0001 - California U.s. Citizens And Nationals Applying For Medi-Cal Must Show Proof Of Citizenship And Identity (Laotian) - Health And Human Services Agency Page 4

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