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)
- Telehealth Flyer – English (PDF)
- Telehealth Flyer – En Español (Spanish) (PDF)
- Health Education Services Flyer – English (PDF)
- Health Education Services Flyer – En Español (Spanish) (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)
- Continuity of Care Request Form – English (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