GVHC Medi-Cal Enrollment Referral Form

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
Name of Golden Valley Employee*
Please enter your name if you are completing this form on behalf of a patient.
Choose language / Escoga lenguaje*

EnglishEspanol
Patient Name*

First NameLast Name
Nombre de Paciente*

Primer NombreApellido
Email
Correo Electronico
County of Residence*
Condado de Residencia*
County Name
Nombre del Condado
Date of Birth*

MonthDayYear
Fecha de Nacimiento*

MonthDayYear
Phone Number *
Please enter a valid phone number.
Numero Telefonico*
Numero telefonico
Patient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Domicilio de Residencia

Nombre de calle

Informacion adicional

CiudadEstado

Codigo Poztal
Golden Valley Clinic Location you attend to:
Escoga a cual clinica de Golden Valley va usted:
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
A GVHC MEDI-CAL Enrollment Representative will be calling you within 48 hours from the time we recieve your request to be contacted.

The working hours of our representatives are:

Monday to Friday between 8:00 am - 6:00 pm Pacific Standard Time.

In the event, the form is filled in a day before a Federally Observed Holiday, the call back will be done on the next working day.

I consent for a MEDI-CAL Enrollment Specialist to contact me via Phone or SMS. I understand that I can opt-out at any time.
Should be Empty:

KEEP YOUR MEDI-CAL

Medi-Cal Enrollment Assistance Form

MANTENGA SU MEDI-CAL

Formato de Asistencia Para Medi-Cal