Joining Healthy Families

We are an authorized Enrollment Entity for the State of California Healthy Families and Medi-Cal for Children and Expectant Mothers, (EE - 89481) We are not a State agency.

Apply For Healthy Families

To apply for The Healthy Families Program, simply complete the Pre-Qualification Assessment below. A friendly and experienced Certified Application Assistant (CAA) will contact you within the next business day after the submission of your information or at a time that is convenient for you.

The phone call takes approximately 20 minutes. Be sure to have the following information available for the call:

A pen or pencil and paper to write down information.
A pay stub received within the past 45 days or the previous year’s Federal Income Tax Form 1040 for everyone receiving income in your household.
If someone is self-employed, the most recent 3-month profit and loss statement or the previous year’s Federal Income Tax Form 1040 and Schedule C.
Birth dates for every child applying in your household.
Amounts for child daycare expenses (only if applicable).
Amounts for disabled dependent care (only if applicable).
Amounts for any child support or alimony either paid or received (only if applicable).

Following the phone call, you will be sent your Rights and Declaration page via fax or mail for your review, date and signature. You will need to fax or mail your signed application to Healthy Families at the address provided. Please be sure to also fax or mail the required supporting documentation indicated on our letter; such as proof of income, expenses, and children’s legal residency. Required documentation may vary depending on your case.

Pre-Qualification Assessment

* Required Fields

Parent's Personal Information

First Name *	Middle Initial	Last Name *

Applicant Date of Birth		Email Address

Contact Information

Please ensure that you are entering the correct phone number. We will contact you using this number.

Home Address 1 *
Home Address 2
Home City *
Home State *
Home five-digit Zip Code *

Please enter your 10 digit phone number in this format : (123) 456-7890

Preferred Phone *	Phone 2	Phone 3
( ) -	( ) -	( ) -
Preferred time to call

Children

Number of Children Under 19 *:

Family Information

Language preference	Family monthly gross income (before tax)	Family size *
		(including yourself and an unborn child, if you have a pregnant mother at home)
Comments/Notifications