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)
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 (PDF)
- Primary Care Physician (PCP) Change Form (PDF)
- Advance Health Care Directive Form (PDF)
- POLST Form
- Care Management Referral Form (PDF)