Member Handbooks and Forms

New Member Materials

• Welcome Letter – English (PDF)
• Welcome Letter – En Español (Spanish)(PDF)
• Welcome Booklet – English (PDF)
• Welcome Booklet – En Español (Spanish) (PDF)
• Health Information Form Flyer – English (PDF)
• Health Information Form Flyer – En Español (Spanish) (PDF)
• How To Get Care – English (PDF)
• How To Get Care – En Español (Spanish) (PDF)
• Health Education Services Flyer – English (PDF)
• Health Education Services Flyer – En Español (Spanish) (PDF)

Member Handbook/EOC

Please note: There are new options for managing your Digital Medical Records.

• California Health & Wellness Member Handbook – English (PDF)
• California Health & Wellness Member Handbook – En Español (Spanish) (PDF)
• California Health & Wellness Member Handbook – Russian (PDF)
  
• CA Cancer Equity Act Referrals Errata - English (PDF)
• CA Cancer Equity Act Referrals Errata - En Español (Spanish) (PDF)
• CA Cancer Equity Act Referrals Errata - Russian (PDF)
• Street Medicine Programs Errata - English (PDF)
• Street Medicine Programs Errata - En Español (Spanish) (PDF)
• Street Medicine Programs Errata - Russian (PDF)

Forms

• Member Claim Form – English (PDF)
• Authorization to Disclose Protected Health Information Form – English (PDF)
• Revocation to Disclose Protected Health Information Form – English (PDF)
• California Children’s Services (CCS) Application – English (PDF)
• Confidential Communication Request Form – English (PDF)
• Confidential Communication Request Form – En Español (Spanish) (PDF)
• Confidential Communication Request Form – Russian (PDF)
• Confidential Communication Revocation (Cancellation) Form – English (PDF)
• Confidential Communication Revocation (Cancellation) Form – En Español (Spanish) (PDF)
• Confidential Communication Revocation (Cancellation) Form – Russian (PDF)
• Continuity of Care Request Form – English (PDF)
• Continuity of Care Request Form – En Español (Spanish) (PDF)
• Continuity of Care Request Form – Russian (PDF)
• Grievance Form
• Health Information Form – English (PDF)
• Health Information Form – En Español (Spanish) (PDF)
• Health Information Form – Russian (PDF)
• MPX flyer – English (PDF)
• MPX flyer – En Español (Spanish) (PDF)
• Notification of Pregnancy Form – English (PDF)
• Notification of Pregnancy Form – En Español (Spanish) (PDF)
• Notification of Pregnancy Form – Russian (PDF)
• Primary Care Physician (PCP) Change Form – English & Spanish (PDF)
• Advance Health Care Directive Form – English (PDF)
• POLST Form