Insuring Kids, LLCHealthy Families Medi-Cal
   ... assisting Families, One Child at a Time
 

Quick Pre-Qualify Questionnaire

Does our Family quailify for Healthy Families or Medi-Cal Programs?
Please enter the following information.

Income and Family Size
Family Size Total family members in which you are connected to through marriage, child in common partner or children under 21 away at school claimed as dependents.
Age of Youngest List an unborn child in the third trimester as age 0.
Annual Family Income $ Total annual income of adult members that support the majority of children.
Income Allowances
Working Adults Include members who are currently working or on temporary disability.
Children in Daycare
(under 2 years old)		 Only count children whom cannot receive care from another household member AND allows the parent(s) to work or attend job training.
(2 years of age and older)
Receive Child or Spousal Support
 Yes No Do any family member receive spousal or child support?
Recipients of Public Aid
(SSI, CalWorks, etc)		 Number of family members whom receive public assistance. (List)
Annual Amount of Aid $ Enter total amount of Public Aid included in the Family Income.
Expense Deductions
Payment of Child or Spousal Support $ Annual amount of child and/or spousal support paid by family members.
Other Deductions $ (leave blank) Use only if given direct instructions.
Contact Information (Optional)
Full Name
Home Phone (xxx-xxx-xxxx) Email Address
     
 

DISCLAIMER: Actual determination is made by the State of California. Insuring Kids, LLC does not limit, restrict or prohibit any person from seeking assistance in completing their application.
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