Our family health plan
A printable from Health Care Complete Guide. Fill it in by hand. Nothing you write is collected by this website.
Our family health plan
Do not write anyone's immigration status on this sheet. Keep it at home.
Each person in our home
- Name: ________ Coverage: full Medi-Cal / restricted scope / ACE / PCAP / Covered California / none
- Name: ________ Coverage: ________
- Name: ________ Coverage: ________
- Name: ________ Coverage: ________
Dates to keep
- Medi-Cal renewal due: ________
- If coverage ended, the date: ________ (3 months to sign up again: by ________)
- Dental work to finish before July 1, 2027: ________
- Premium from July 1, 2027? Yes / No. Amount: ________
Our doctors
- Clinic: ________ Phone: ________
- Does it take Fee for Service Medi-Cal in 2027? Yes / No
- Where is each person's Medi-Cal BIC card? ________
Numbers
- San Mateo Medi-Cal 1-800-223-8383 / Santa Clara (408) 758-3800
- ACE 650-616-2002 / PCAP (888) 363-3394, option 1 / HAP 866-967-4677
- Ravenswood enrollment 650-330-7416 / WIC 1-800-852-5770
- Bay Area Legal Aid advice line 1-800-551-5554
- Emergency: 911. Crisis: call or text 988.
Before changing any benefit: ask a legal helper if public charge applies to us. Name and date: ________
From Health Care Complete Guide. Facts checked October 21, 2026. Free information, not legal or medical advice.