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This program is administered
by the Managed Risk Medical Insurance Board (MRMIB).

Most items are in Acrobat pdf format, and you will need Acrobat Reader to see them. Click here to download a free copy of Adobe Acrobat Reader if you do not have the program.

Annual Eligibility Review Form (English) 1,746 KB
Annual Eligibility Review Form (Spanish) 5,045 KB
Annual Eligibility Review Form (Armenian) 2,252 KB
Annual Eligibility Review Form (Chinese) 1,910 KB
Annual Eligibility Review Form (Farsi) 1,821 KB
Annual Eligibility Review Form (Hmong) 8,417 KB
Annual Eligibility Review Form (Khmer/Cambodian) 7,754 KB
Annual Eligibility Review Form (Korean) 1,922 KB
Annual Eligibility Review Form (Russian) 8,887 KB
Annual Eligibility Review Form (Vietnamese) 5,019 KB

Last updated 02/2010

After you download and fill out the Annual Eligibility Review form, mail to:

Healthy Families/Medi-Cal for Children & Pregnant Women
P.O. Box 138005
Sacramento, CA 95813-8005