Download Forms and Information

Get Healthy Families forms and information that you can store on your computer, print and use. The forms and information you can get are listed below.

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.

Forms

• Applications
  In multiple languages, with or without instructions.
• Add a Person
  When you need coverage for another person in your family.
• Annual Eligibility Review
  To continue coverage each year.
• Review and Continued Enrollment
  If you do not agree with a decision Healthy Families made to disenroll someone in your family. Must be submitted prior to the date of disenrollment.
• Re-enrollment
  To re-enroll people who were in the program before. For instructions, click here.
• Program Review Form
  If you do not agree with a decision Healthy Families made about your eligibility, coverage date, or disenrollment.
• Electronic Funds Transfer Form
  To sign up for Electronic Funds Transfer for your Healthy Families account.
• Authorized Representative Form Revised
  To give us permission to speak about your case with someone other than yourself.
• EE/CAA Authorization Form (Enrollment Entity) New
  To give your permission for Healthy Families and Medi-Cal to speak with a representative of the Enrollment Entity about your application.
• Premium Re-Evaluation Form
  If your income has gone down, you may be able to lower your premiums.

General Information

• Handbook
  English, download in sections
• Family members and income
  A brochure about how Healthy Families figures income and family size and whether or not a person qualifies for the program.
• Immunization Schedule New
• Preventive Health Screenings New
• Preventative Dental Care (PDF 1,355 kb) New

Family Contribution Sponsorship forms

• Sponsor Registration
  To sponsor a family by paying the family's premiums for one year.
• Sponsorship Payment
  For sponsors and their applicants, to accompany payment. For more information about Family Contribution Sponsorship, see Sponsorship.

For Certified Application Assistants and Enrollment Entities: Information and Forms

Sample Documents & Worksheets

• Sample Profit and Loss Statement
• Sample Self Affidavit of Income Letter
• Sample Employer Letter
• Income Calculation Worksheet
• Income Calculation Worksheet instructions
• Rental Income Worksheet
• Sample Childcare Letter
• Sample Child Support Letter
• Sample Gift Letter
• Income Documentation for Renting a Room

Go to For CAAs and EEs to find additional resources:

• Update Bulletins
• Marketing Materials
• CAA Reference Manual
• CAA Collateral Materials Order Form
• EE Information Change Form