Zocalo Health Medi-Cal Referral Form
For leads identified as needing Medi-Cal assistance.
For Internal Use
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Zocalo Health Team Member
*
What is the source / event of this submission?
*
ZH Team Member Role
*
PSS
CES
CHW
Other
About the Patient
What is the need? (please do not select Other unless in complex circumstances) For any further details, use 'Notes' section below.
*
Medi-Cal Application Assistance
Medi-Cal Recertification Assistance
CalFresh Application Assistance
CalFresh Recertification Assistance
Change in Insurance Assistance
Assistance with Pending Application
Other: Specify
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Language
*
English
Spanish
Other: Specify
County
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Best Time to Call
*
Morning
Afternoon
Evening
Other: Specify
Create Patient Profile in Fold. Mark active, and schedule Health Insurance Appointment - Initial (15 minutes). Enter Fold Link below
*
Please make an appointment in Fold/Athena for this individual to be directly assisted by our Medi-Cal Support Specialist. Has a Health Insurance Support - Initial 15 minute appointment been scheduled?
*
Yes
No
Are you willing to complete a Release of Information to enable Zocalo Health to advocate for you during the application process?
*
Yes
No
Provide any additional notes
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Submit
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