KEEP YOUR MEDI-CAL
Medi-Cal members will need to renew their benefits this year to maintain their coverage.
Medi-Cal Enrollment Assistance Form
Please complete the form below to schedule a phone appointment and receive assistance in Medi-Cal enrollment. The enrollment team is available to assist you Monday to Friday 8am to 6pm by calling 209-237-1610.
MANTENGA SU MEDI-CAL
los miembros de Medical deberán renovar sus beneficios este año para mantener su cobertura.
Formato de Asistencia Para Medi-Cal
Favor de completar este formato para agendar una cita por telefono para ayudarle aplicar para Medi-Cal. El equipo de inscripción esta disponible de Lunes a Viernes de 8am a 6pm PST llamando a 209-237-1610.
Pick select one of the following / Por favor escoga uno de los siguientes
Please Select
I'm a Golden Valley employee
I'm a patient / Soy un paciente
Name of Golden Valley Employee
*
Please enter your name if you are completing this form on behalf of a patient.
Choose language / Escoga lenguaje
*
English
Espanol
Patient Name
*
First Name
Last Name
Nombre de Paciente
*
Primer Nombre
Apellido
Email
Correo Electronico
County of Residence
*
Select a county
Merced
Stanislaus
San Joaquin
Other
Condado de Residencia
*
Escoga Condado
Merced
Stanislaus
San Joaquin
Otro
County Name
Nombre del Condado
Date of Birth
*
-
Month
-
Day
Year
Fecha de Nacimiento
*
-
Month
-
Day
Year
Phone Number
*
Please enter a valid phone number.
Numero Telefonico
*
Numero telefonico
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Domicilio de Residencia
Nombre de calle
Informacion adicional
Ciudad
Estado
Codigo Poztal
Golden Valley Clinic Location you attend to:
Please Select
Merced
Merced Dental
PromptCare
Women's Health
Merced Northview
O'Banion Center
Modesto Center of Home
Empire
Florida North
Florida Suites
Hanshaw School
Mission
Riverbank
Robertson Road
Tenaya
Tully
Women's Health
West Modesto
Ceres - 3rd Street
Ceres - East
Ceres - Whitmore Avenue
Dos Palos
Le Grand
Le Grand Dental
Los Banos Medical
Los Banos Dental
Manteca - 250 Northgate Drive
Manteca - 302 Northgate Drive
Newman
Patterson
Planada
Turlock - Olive Avenue
Turlock - West
Turlock - Monte Vista
Turlock - Pediatrics
Westley
PACE
Escoga a cual clinica de Golden Valley va usted:
Please Select
Merced
Merced Dental
PromptCare
Women's Health
Merced Northview
O'Banion Center
Modesto Center of Home
Empire
Florida North
Florida Suites
Hanshaw School
Mission
Riverbank
Robertson Road
Tenaya
Tully
Women's Health
West Modesto
Ceres - 3rd Street
Ceres - East
Ceres - Whitmore Avenue
Dos Palos
Le Grand
Le Grand Dental
Los Banos Medical
Los Banos Dental
Manteca - 250 Northgate Drive
Manteca - 302 Northgate Drive
Newman
Patterson
Planada
Turlock - Olive Avenue
Turlock - West
Turlock - Monte Vista
Turlock - Pediatrics
Westley
Additional Information
Please include any additional relevant information which will help expedite and better serve you in your application process.
Informacion Adicional
Porfavor incluya cualquier informacion adicional que usted crea sea importante pero mejor atendarlo(a). Gracias
Submit / Enviar
Should be Empty: