The Birth of a Child "*" indicates required fields Step 1 of 7 14% I have an open CalFresh (food stamps) or MediCal case:* I have a current open case in Contra Costa County I have a open case outside Contra Costa County I need to open a case with Contra Costa County Let us help you apply: Online - BenefitsCal Telephone - (866) 663-3225 Mail - Mail in an application to EMPLOYMENT AND HUMAN SERVICES CONTRA COSTA COUNTY PO BOX 4114 Concord, Ca 94524-9700 In Person or Drop off - Drop off your competed application to a local district office Fax - (925) 228-0310 Return to Help Page Please contact your current county for assistance with your case. Please visit the California Department of Heath Care Services website for county contact information Return to Help Page Consent*EHSD uses secure encryption to ensure your privacy and protect your data. You will receive a confirmation e-mail after you submit your information. Data you submit through this form will not be available on ehsd.org or any publicly accessible systems. I agree to the privacy policy. Confirmation NumberThis field is hidden when viewing the formDate for Confirm #Hidden field used to configure date mergetag output to confirmation number MM slash DD slash YYYY Name* First Last County Case NumberYour case number is located at the top of any Notice of Action you have received in the mail from Contra Costa County and looks like 1F12345 If you do not know your case # please provide as much info as possible.0 of 7 max charactersYour Date of Birth (DOB)* MM slash DD slash YYYY Do You Have a Social Security Number (SSN)?* Yes No Last 4 digits of SSN0 of 4 max charactersPhone*Do you have an email address?* Yes No Email Enter Email Confirm Email What is your baby’s full name:* First Middle Last Your baby’s Date of Birth:* MM slash DD slash YYYY Your baby’s gender:* Male Female What is the name of the baby’s Mother?* First Last What is the name of the baby’s Father? First Last Where was the baby born? (City & State)* City State StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific I would like to upload an image to verify your change, such as birth certificate and/or social security card* Yes No Upload your image(s) below:There is a 2MB file size limit Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, tif, tiff, doc, docx, xls, xlsx, Max. file size: 2 MB, Max. files: 3. Do you need to report an additional change?* Yes No NameThis field is for validation purposes and should be left unchanged.
