Dear Parent, Student, or employee:

This school year has been full of challenges, obstacles, opportunities, and achievements. From embracing safety procedures to [preparing for or implementing] distance learning, we have done everything possible to ensure students are continuing to learn in a safe environment with as little disruption as possible. Currently under the Cares Act, all private, Medicare and Medi-Caid plans are required to cover covid-19 testing with “no pocket of pocket” costs such as deductibles, copayments, and co-insurances to their members.

For all uninsured CA residents:

Whether or not you are currently covered with active medical insurance, please complete the following form as it pertains to you. Those not currently covered by insurance will be directed to complete California's application for Covid-19 coverage.

I know that under federal law, DHCS does not unlawfully discriminate on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, sexual orientation, or any other basis protected by federal or State civil rights laws.

Complaints may be filed by calling the Office of Civil Rights, Department of Health Care Services at (916) 440-7370 or by written correspondence to P.O. Box 997413, MS 0009, Sacramento, CA 95899-7413, or by email addressed to CivilRights@dhcs.ca.gov.

I know that information on this form will be used to determine eligibility for health coverage, help paying for coverage, and for lawful purposes of programs that help pay for coverage.

If anyone on this application is eligible for Medi-Cal, I grant to the California Department of Health Care Services our rights to pursue and get any money from other health insurance, legal settlements, or other third parties.

We need the information on this application to check your eligibility for help paying for coverage of COVID-19 testing, testing-related, and treatment costs. We’ll check your answers using information in our electronic databases and databases from Social Security, and the Department of Homeland Security. If the information doesn’t match, we may ask you to send us more information.

I have the right to know how my protected health information may be used and disclosed, and what my privacy rights are. The Notice of Privacy Practices (NPP) provides this information and is available at https://www.dhcs.ca.gov/formsandpubs/laws/priv/Pages/NoticeofPrivacyPractices.aspx

This application is for the COVID-19 Uninsured Group program administered by the Department of Health Care Services (DHCS). The personal and medical information you provide on it is private and confidential. DHCS needs it to identify you and to administer the COVID-19 Uninsured Group program.

We will share your information with other state, federal, and local agencies, contractors, health plans, and programs only to enroll you in a plan or program or to administer programs, and as described in the Notice of Privacy Practices.

You must answer all of the questions on this application unless they are marked “optional.” If your application is missing anything that we require, we will contact you to get it. If you do not provide it, we will not be able to make a decision on your application. You may have to submit a new application, or your application for COVID-19 Uninsured Group benefits may be denied.

For more information or to see Department of Health Care Services records, contact the Information Protection Unit at P.O. Box 997413, MS 4721 Sacramento, CA 95899-7413 Phone: 1-866-866-0602 TTY: 1-877-735-2929.

These state and federal laws give us the right to collect and keep the information on the application: DHCS: CA Welfare and Institutions. Code § 14011 and Article 3, Chapters 5 and 7, Parts 2 and 3, Division 9; Covered CA: 42 U.S.C. § 18031; CA Government Code §§ 100502(k) and 100503(a).

If I think the Medi-Cal program has made a mistake, I can appeal the decision. To appeal means to tell someone at the Medi-Cal program that I think the decision is wrong and ask for a fair review of the action.

know that I can find out how to request an appeal, including an expedited appeal, by calling 1-800-743-8525 (TTY: 1-800-952-8349) for the Medi-Cal program.

I know that I must file an appeal within 90 days of the decision notice.

I know that I can represent myself or have someone else represent me in my appeal, such as an authorized representative, a friend, a relative or a lawyer.

I know that all hearings will be conducted by telephone or video conference unless I request an in-person hearing.

I know that if I need help the Medi-Cal program can explain my case to me.

I know that someone at the Medi-Cal program can explain the circumstances when my eligibility may be maintained or reinstated pending an appeal decision.

By signing, I declare that what I say in this form is true, complete, and correct.

I have read and understand this application.

I understand that this application is only to get help paying for certain coronavirus (COVID-19) testing, testing-related, and treatment costs. To see if I am eligible for other health care benefits and services through Medi-Cal or Covered California, I should complete a full application at www.coveredca.com.