Department of Health Care Services (DHCS) Assistance Form

Contact Information

Request Details

What do you need assistance with? *

Medi-Cal Enrollment

Adult Health (Veterans, Seniors, Long-Term Care, etc.)

Women's Health

Children & Youth

Mental Health or Substance Use Disorder Services

Other

If you selected other, please specify here.

What are you trying to do? *

Apply for benefits

Request services

Request a Hardship Waiver

Resolve a billing issue

Other

If you selected other, please specify here.

Have you already contacted another elected official? *

Yes

No

If Yes, please list any other elected officials you have contacted for assistance.

Please provide a brief description of your issue.

Do not submit any personal identifiable information through this form that is not specifically requested. if the Assemblymember's office needs additional information, the office will contact you to request that information.