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Download an Electronic Funds Transfer Form
Most items are in Acrobat pdf format, and you will need Acrobat Reader to see them. Click
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- Electronic Funds Transfer Form (English) 297 KB
- Electronic Funds Transfer Form (Spanish) 331 KB
- Electronic Funds Transfer Form (Chinese) 292 KB
- Electronic Funds Transfer Form (Korean) 283 KB
- Electronic Funds Transfer Form (Vietnamese) 320 KB
After you download and fill out the Electronic Funds Transfer form, mail to:
Healthy Families/Medi-Cal for Children & Pregnant Women
P.O. Box 138005
Sacramento, CA 95813-8005