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Free Medi-Cal Assessment

If you prefer to print this form and fill out then fax/email back to us, please click here. When finished, please fax back to (877) 274-7948 or email to    IMPORTANT NOTE: (2/6/19) Please choose the Print and email or fax back to us option as we are experiencing technical issues with the SUBMIT option at this time..We don’t want to miss assisting you so Feel Free to call in with your assessment (877-633-4435) until we can assure that technical issues are resolved.

Please fill out this form to the best of your knowledge. This information will not be shared without permission.

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