The Newborn Referral Form (MC 330) is used to assist a Medi-Cal eligible mom to report the birth of her child(ren) to Medi-Cal.
Who can complete the form?
The form can be completed by the parent(s) of the newborn as well as hospitals, clinics, urgent care centers, independent nurse-midwives, outreach workers, Women, Infants and Children (WIC) groups, and others acting on mother’s behalf.
Newborn Referral Form Facts
The Newborn Referral Form is not an application for Medi-Cal. However, by completing the information on the form you help the county confirm the eligibility of the newborn.
Any changes to the household must be reported to the county, so this information should be turned in quickly.
The mother may also report the birth by phone to her eligibility technician.
If you are acting on behalf of the mother and are not a spouse, relative, or guardian, then you must complete and sign Section C of the Newborn Referral Form.
For additional information you can call the Newborn Referral Information Line toll free at 1-800-281-9799
Where/How do I send the form?
The form can be submitted by fax or US mail.
The Newborn Referral Form (MC 330) can be mailed to the county at:
Social Services Agency
P.O. Box 25192
Santa Ana, CA 92799-9511
The Newborn Referral Form (MC 330) can be faxed to the county Social Services Agency at 714-435-4625
For additional information you can call the Newborn Referral Information Line toll free at 1-800-281-9799.