State Benefits Application and Enrollment Forms

California Healthy Families (SCHIP) Homepage

Low cost insurance for California children and teens. Provides health, dental and vision coverage to children who do not have insurance and do not qualify for free Medi-Cal.

• Application
  Available for download in multiple languages, with or without instructions.
• Add a Person
  When you need coverage for another person in your family.
• Annual Eligibility Review
  Necessary to continue receiving 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 Form
  Complete this in order to re-enroll individuals who were in the program before.
• Program Review Form
  Submit this if in disagreement with a decision SCHIP made about eligibility, coverage date, or disenrollment.
• Electronic Funds Transfer Form
  Sign up for Electronic Funds Transfer for your Healthy Families account.
• Authorized Representative Form
  Grants SCHIP permission to discuss your case with others.
• EE/CAA Authorization Form (Enrollment Entity)
  Grants permission for Healthy Families and Medi-Cal to speak with a representative of the Enrollment Entity about your application.
• Premium Re-Evaluation Form
  Use this form if your income has gone down, you may be able to lower your premiums.

California Medicaid

• California Department of Health Care Services Homepage
  Medi-Cal is California's Medicaid health care program. Program pays for a variety of medical services for children and adults with limited income and resources.
  
  Enroll children and pregnant women in the Medi-Cal or Healthy Families program. Forms available with or without instructions for easy and quick download.
• Applications
  Applications for individuals and providers to participate in Health Care Services programs.
• Healthy Families/Medi-Cal Joint Application (English)
  Healthy Families/Medi-Cal Joint Application (Multiple Languages)
• Medi-Cal Mail In Application Form (English)
  Medi-Cal Mail In Applications (other languages)
• Health Insurance Premium Payment Application
  Health Insurance Premium Payment Application (Spanish)
• Health Insurance Questionnaire (English)
  Health Insurance Questionnaire (Spanish)

California CALWORKS (TANF)

The School Breakfast and Lunch Programs make nutritionally balanced, low-cost or free meals available to school children each school day.

• Food Stamp Application
  Food Stamp Application (Other Languages)
• California Deparment of Social Services Homepage

California Unemployment Insurance

Unemployment insurance benefits provide temporary financial assistance to workers unemployed through no fault of their own who meet California's eligibility requirements.

• Online Unemployment Insurance Application
  Available in English or Spanish.

Employee / Claimant Forms

• Unemployment Insurance Application (English / Spanish)
  Application for UI benefits. Print form, complete and fax or mail to EDD to file UI claim.
• Request for Eligibility Information
  Form sent to claimants who missed a reqd. Reemployment and Eligibility Assessment appointment. Claimants must complete form and questionnaire and mail it to the EDD within 10 days of mailing date listed on form.
  
• Request for Eligibility Information (Spanish)
  
• Reemployment And Eligibility Assessment Questionnaire
  Form sent to claimants scheduled to attend a Reemployment And Eligibility Assessment (REA) appointment. Claimants must complete the form prior to REA appointment.
  
• Reemployment And Eligibility Assessment Questionnaire (Spanish)
  
• Employment Development Department Appeal Form
  Form for claimants and employers to appeal an eligibility decision made by the Department.
  
• Application for Trade Adjustment Assistance (TAA)
  Trade affected workers can apply for participation in the Trade Adjustment Assistance (TAA) or North American Free Trade Agreement-Transitional Adjustment Assistance (NAFTA-TAA) programs.
  
• Authorization for Release Unemployment Insurance Records for Retired Annuitant
  Form for retired annuitant to request UI records for hiring state agency.
  

Employer Forms

• Notice of Reduced Earnings (English/ Spanish)
  DE 2063 form is used by employers to certify employees for partial benefits.
• Notice of Reduced Earnings (Fisherperson)
  Form DE 2063F is used by employers to certify employees for partial benefits for fisherpersons.
• Work Sharing- Unemployment Insurance Plan Application
  Completed by employers to participate in the Work Sharing program.
• Wages Notice Request-Holiday/Vacation Pay
  Complete this form for employees that will receive holiday or vacation pay.
• Wages Notice Request, Bonus Pay
  Complete this form only if your company is paying some type of bonus pay to the affected employees.
• Wages Notice Request Separation Pay
  Form for company paying in lieu-of-notice pay or other types of post-employment payments to terminated employees (excluding regular wages).
• Prior Wages Notice Correction/Update Request
  Report information to be corrected on a current notice, or provide information regarding a more recent layoff.

California Department of Public Health

• Health Care Decisions
  Information regarding your living will and Durable Power of Attorney for Advanced Health Care Directive.
• Advance Health Care Directive
• Certificate and Licenses Request Forms
  Birth, death, fetal death, still birth, and marriage certificates.
• HIPAA/Privacy Complaint Form
  Form for professional office to provide patients.
• Licensing and Certificates
  Forms and applications for healthcare professionals and healthcare facilities.
• Medical Marijuana Program
  Applications and forms for licensing.
• 
  Forms and applications to partake in Family PACT (Planning, Access, Care, and Treatment).
• Additional Public Health Forms
  Provides link to California Department of Health online form and publications library.

Privacy Forms

Privacy forms help individuals access their protected health information and exercise other privacy rights. These are the official HIPAA forms used by DHCS health plans covered by HIPAA.

• Privacy Complaint
• Whistleblower Complaint
• Authorization
• Additional Forms by Program
  Medi-Cal Forms, California Children's Services Forms, and more.

California Children's Services (CCS) HIPPA Forms

• Northern California Regional Office / San Francisco
• Southern California Regional Office
• Sacramento Regional Office
• Genetically Handicapped Persons Program HIPAA Forms
• Additional Forms by Program

California Energy Assistance Programs

• Low Income Home Energy Assistance Program (LIHEAP)
  Eligible low-income persons can receive financial assistance to offset the costs of heating and/or cooling dwellings, and/or have their dwellings weatherized to make them more energy efficient. The Energy Crisis Intervention Program (ECIP) provides payments for weather-related or energy-related emergencies. Low-Income Home Energy Assistance Program (LIHEAP)
• Weatherization Assistance Program (WAP)
  Reduces the heating and cooling costs for low-income families by improving energy efficiency of homes. Program focuses on elderly residents, individuals with disabilities, and families with children.
• Sacramento Regional Office
• Genetically Handicapped Persons Program HIPAA Forms
• Additional Forms by Program

Miscellaneous Links and Forms