Member Handbooks and Forms

New Member Materials

• Welcome Letter – English (PDF)
• Welcome Letter – Spanish (PDF)
• Welcome Booklet – English (PDF)
• Welcome Booklet – Spanish (PDF)
• Health Information Form Flyer – English (PDF)
• Health Information Form Flyer – Spanish (PDF)
• How To Get Care – English (PDF)
• How To Get Care – Spanish (PDF)
• Telehealth Flyer – English (PDF)
• Telehealth Flyer – Spanish (PDF)
• Health Education Services Flyer – English (PDF)
• Health Education Services Flyer – 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)
• Changes to Non-Emergency Medical Transportation (NEMT) – English (PDF)
• California Health & Wellness Medi-Cal Postpartum Care Extension (PCE) and Rapid Whole Genome Sequencing (rWGS) Errata – English (PDF)
• California Health & Wellness Medi-Cal Postpartum Care Extension (PCE) and Rapid Whole Genome Sequencing (rWGS) Errata – En Español (Spanish) (PDF)

Forms

• Member Claim Form (PDF)
• Authorization to Disclose Protected Health Information Form (PDF)
• Revocation to Disclose Protected Health Information Form (PDF)
• California Children’s Services (CCS) Application (PDF)
• Continuity of Care Request Form (PDF)
• Grievance Form
• Health Information Form (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 (PDF)
• Advance Health Care Directive Form (PDF)
• POLST Form
• Care Management Referral Form (PDF)