The California MC 371 form, titled “Additional Family Members Requesting Medi-Cal,” is the two-page document you use to add a person to an existing Medi-Cal case. You download it from the California Department of Health Care Services (DHCS), fill in personal, income, and expense details for each person being added, sign the certification on page two, and return it to the same county office that handles your current Medi-Cal file.1California Department of Health Care Services. Additional Family Members Requesting Medi-Cal – MC 371
When to Use the MC 371
Use this form when your household already has a Medi-Cal application on file and you need to add someone who wasn’t on the original submission. A new baby, a spouse who has moved in, or a relative who now qualifies are the common reasons. If you’re starting a Medi-Cal case from scratch, this isn’t the right form.
What to Gather Before You Start
For each person you’re adding, pull together:
- Full legal name, plus any different name on the birth certificate.
- Social Security number.
- Date and place of birth, U.S. citizenship or national status, and if not a citizen, the date they arrived in the country.
- Benefits Identification Card (BIC) number if the person was previously on Medi-Cal.
- Any current health insurance, dental insurance, or Medicare details.
- Income documentation: pay stubs, Social Security award letters, pension statements, showing gross amounts and how often they’re paid.
- Expense records for child day care, disabled dependent care, and any court-ordered child or spousal support.
For a household member with a disability, note the date the disability began. For a pregnant member, note the expected due date and how many babies are expected.1California Department of Health Care Services. Additional Family Members Requesting Medi-Cal – MC 371
Page One: Applicant, Spouse, and Children
The top block is for the applicant or caretaker: the adult responsible for the household’s Medi-Cal case. Enter name, relationship to any children in the home, gender, and marital status. If the person is pregnant, check the box and add the due date and number of babies expected. Fill in Social Security number, date of birth, and place of birth. Answer the citizenship question, and if not a U.S. citizen or national, enter the arrival date. Check whether the person is requesting coverage for themselves or is listed only as caretaker for others. Add the BIC number if there is one.1California Department of Health Care Services. Additional Family Members Requesting Medi-Cal – MC 371
The spouse or other parent section mirrors the applicant section field for field. Complete it if a spouse or second parent lives in the household and is being added.
The child section asks for the same identifiers as the adult sections, and adds a few questions specific to minors: whether the child lives in the home, whether the child attends school, the mother’s name and the father’s name, and whether either parent is deceased, absent from the home, incapacitated, or unemployed. For an unborn child, write “Unborn” in the name field. If there isn’t enough space for every child, attach a separate sheet with the same information.
Page Two: Insurance, Injury Claims, and Retroactive Coverage
Page two opens with existing coverage. Report whether anyone being added already has health insurance, dental insurance, or Medicare. Having other coverage doesn’t disqualify anyone from Medi-Cal; the state uses the answer to coordinate benefits and avoid duplicate payments.
Next, indicate whether anyone in the household has filed a lawsuit over an accident or injury. Medi-Cal may have a right to recover costs from a settlement or judgment, so answer accurately.
One box is easy to miss: retroactive coverage. The form lets you request Medi-Cal for medical bills incurred during the three months before the application date. If anyone being added had medical expenses in that window, check the box.1California Department of Health Care Services. Additional Family Members Requesting Medi-Cal – MC 371
Military Service and Information Sharing
A short section asks whether anyone in the household has served in the U.S. military. If yes, list the person’s name and relationship. Veterans and dependents may qualify for additional benefits, and the answer helps the county route the case.
Two information-sharing checkboxes are set to share by default. The county will share the application with Healthy Families if a child no longer qualifies for free Medi-Cal, and with Healthy Kids or a similar county program if a child doesn’t qualify for full-scope Medi-Cal. Check the corresponding box to opt out of either.1California Department of Health Care Services. Additional Family Members Requesting Medi-Cal – MC 371
Reporting Income and Expenses
List each household member who earns money. For each, put down the source (job wages, Social Security, pension, self-employment, and so on), how often the income comes in (weekly, biweekly, monthly), and the gross amount before deductions. Providing the earner’s Social Security number is listed as optional in this section, but including it speeds up verification.
Report monthly expenses in the categories the form provides:
- Child day care or disabled dependent care: name and age of the person receiving care, the amount paid, and how often.
- Court-ordered child support: who it’s paid to, who pays it, and the amount.
- Court-ordered spousal support: recipient, payer, and amount.
These deductions can change eligibility and the share of cost assigned to the household, so report them even when the amounts seem minor.1California Department of Health Care Services. Additional Family Members Requesting Medi-Cal – MC 371
Signing and Submitting the Form
The certification at the bottom of page two needs a signature and date. The applicant or caretaker listed at the top of the form is the person who signs, and the signature certifies that the information is true and correct.
Send the completed MC 371 to your local county social services or human services agency, the same office that handles your existing Medi-Cal case. County offices take forms in person, and many accept them by mail. Some counties allow uploads through an online benefits portal, though availability varies. The county contact information is usually printed on any Medi-Cal correspondence you’ve received.
What Happens After You Submit
The county verifies the information against state and federal records. It is required to act on the application within 45 days for most categories of Medi-Cal, or 90 days if a disability determination is involved. If more documentation is needed, the county will contact you in writing. Keep a copy of the completed form, the supporting documents, and any receipts or confirmation numbers in case a question comes up later.