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Application Requirements for Minor Consent Services
Applications for Minor Consent services may be submitted either in-person or by telephone. The applicant may choose to be interviewed in person or by telephone. Applications and all required forms for Minor Consent Services must be signed either with a wet signature, telephonic signature, or through DocuSign.
A Minor Consent application is valid for one month only. The child must reapply and complete a new MC 4026 (except for outpatient mental health services) and a MC210 or a printed and signed Statement of Facts (SOF) for each month services are needed.
The EW must review the MC 4026 with the minor and verify that the information on the MC 4026 has not changed. The MC 4026 contains specific rights and responsibilities that must be read and signed upon initial application and all following redeterminations.
Reminder: All minor consent cases are confidential and parents are not to be contacted regarding their child's receipt of the requested services. A minor must apply for minor consent services.
Parent(s) may not apply on behalf of their minor child. Whether applying or renewing eligibility for the Minor Consent program in person or over the phone, contact must ONLY be directed to the minor applying for or renewing services, and the confidentiality requirement must not be waived under any circumstance.
Forms
The application requirements of the Minor Consent program include the following:
- Request for Eligibility Limited Services (MC 4026)
- Statement of Facts MC 210 (printed copies of this form are provided by DHCS. This form is obsolete for all other purposes)
Important: The SSApp must NOT be used for Minor Consent.
- Supplement to Statement of Facts for Retroactive Coverage/Restoration” (MC 210A) (If retro Medi-Cal is requested.)
- Important Information for Persons Requesting Medi-Cal” (MC 219)
Reminder: The applicant is not required to sign the MC 219. However, it must be documented in the case Journal page that the form was given to the client and the date provided. An MC 219 is required at intake and at least every 12 months at redetermination, or when a break in aid of one month or more occurs, but not every month when an MC 4026 is completed.
Related Topics
Definition of “Child” for Minor Consent