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1. Download, print, and complete Section 1 of the Certification Form PDF in your desired language, if available:
Download the PDF form and Complete Section 1:
Note: Use only Acrobat Reader to complete the PDF Form.
Request a Form by Mail:
You also may request a Certification Form in your desired language by mailing to the California Connect Contact Center at P.O. Box 30310 in Stockton, CA 95213.
Request a Form by Phone/VP:
You also may contact us at 1-800-806-1191 in the following languages of English, Spanish, Mandarin, Cantonese, Hmong, Vietnamese, Russian, and ASL to request a form.
- English: 1-800-806-1191
- Spanish: 1-800-949-5650
- TTY: 1-800-806-4474
- Mandarin: 1-866-324-8747
- Cantonese: 1-866-324-8754
- Hmong: 1-866-880-3394
- Vietnamese: 1-855-247-0106
- Russian: 1-855-546-7500
2. Contact your preferred Professional to complete and sign Section 2 of the form:
The following medical professionals are authorized by the State of California to sign Section 2:
- Licensed Medical Doctor: May sign for people with any disability.
- Licensed Physician Assistant: May sign for people with any disability.
- Licensed Nurse Practitioner: May sign for people with any disability.
- Department of Rehabilitation Counselor [VRC, RCB or RCD]: May sign for people with any disability.
- Licensed Optometrist: May only sign for people who are blind or partially-sighted.
- Licensed Audiologist: May only sign for people who are deaf or hard of hearing.
- Licensed Speech Language Pathologist (SLP): May approve applications for applicants with speech disabilities.
- Superintendent or school audiologist at the California School for the Deaf in Riverside and Fremont: May only sign for current students who are deaf or hard of hearing.
- Licensed Hearing Aid Dispenser: Dispenser must have the customer record on file, and may only sign for people who are deaf or hard of hearing.
If you do not have a doctor, you may stop in and visit one of our service centers or call us for assistance in finding a certified medical professional who could sign your Certification Form.
3. Mail, Email, or Fax your completed Certification Form to a California Connect Contact Center:
By Mail:
State of California
California Connect Contact Center
郵政信箱 30310
Stockton, CA 95213
By Email:
info@caconnect.org
By Fax:
1-800-889-3974
OR drop off your Certification Form at one of the California Connect Service Centers:
All California Connect Service Centers are open Monday through Friday, 8:00 am – 5:00 pm, closed 11:30 am - 12:30 pm (excluding holidays). Please call the Contact Center at 1-800-806-1191 to confirm hours of operation for all Service Centers.
Once your Certification Form is approved, you will receive a letter or call. California Connect will contact low-vision and blind customers by phone before sending a letter. The letter or call will instruct you to either get in touch with the California Connect Contact Center or visit a California Connect Service Center. You will be assessed for the best equipment and services to meet your needs. Additional training is also available by getting in touch with the California Connect Contact Center or visiting a California Connect Service Center.
Go here to see equipment grouped by approved certification.
Let California Connect know if there is some way to help improve the application process by filling out the Program Feedback Form.
To view pdf forms, download the most recent version of Acrobat Reader.