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 on the icon at left to download a free copy of Adobe Acrobat Reader if you do not have the program.

Forms

	Application
	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

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 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

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