Medical Choice Form – Fill Out and Use This PDF

The Medical Choice Form is a critical document that allows individuals and families receiving Medi-Cal benefits to specify their health plan preferences, including their choice of doctor or healthcare service. By meticulously completing both sides of the form, applicants clearly communicate their healthcare needs and changes, ensuring they receive the most suitable care. For those needing assistance with filling out the form, free help is available by calling 1-800-430-4263. Ready to take charge of your Medi-Cal health care options? Click the button below to start filling out your Medical Choice Form.

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Medical Choice Form PDF Details

Navigating the healthcare landscape can be complex and fraught with choices that directly impact one’s health and well-being. The Medi-Cal Choice Form emerges as a crucial tool in this journey, empowering individuals and families to take control of their healthcare decisions. It requires applicants to provide comprehensive information, including personal details, for each family member receiving Medi-Cal, ensuring choices are informed and tailored to specific needs. The form accommodates choices among various healthcare plans like Blue Cross, Care 1st, HealthNet, Kaiser, and Western Health Advantage, in addition to the option of remaining with regular Medi-Cal. Specific doctor or clinic codes associated with the chosen plan must be entered, a step that highlights the importance of understanding one's healthcare provider network. The form underscores the need for meticulousness by prompting for complete filling on both sides and offers support via a free help line, reflecting an awareness of the challenges many face in making these decisions. Acknowledgment sections reinforce the gravity of choices made, informing applicants of how their information is used and introducing the concept of binding arbitration for certain choices, such as joining Kaiser. This element of the form illustrates the broader implications of selecting a healthcare plan, intertwining legal understanding with medical decision-making. The process concludes with a requirement for signatures, cementing the choices and ensuring accountability and understanding from all parties involved. The Medi-Cal Choice Form thus stands as a testament to the structured yet flexible approach required to navigate California’s healthcare system, embodying the intersection of healthcare, law, and personal choice.

Question	Answer
Form Name	Medical Choice Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	medical choice form ca, medi cal healthcare options form, medi cal choice, medi cal choice form download

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Medi-Cal Choice Form Please ﬁll in both sides.

For free help ﬁlling out this form, call 1-800-430-4263.

1. Please print. Use a blue or black pen.					3. Fill in all information for each person in your household who gets Medi-Cal.
2. Fill in the	to show your choice. Fill it in completely:				4. If you have more than 3 family members, call 1-800-430-4263 to ask for another form.

Head of Household								Sex:	Male	Female
__________________________________			________________________________________					( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___
Ç First Name			Ç Last Name					Ç Area Code		Ç Telephone or Cell Phone Number
__________________________________________________________						____________________________________ ___ ___ ___ ___ ___
Ç Home Address: house number, street name, apartment number						Ç City				Ç Zip Code

1st Applicant
__________________________________			________________________________________					Sex:	Male	Female
Ç First Name			Ç Last Name
___ ___ ___	– ___ ___ –	___ ___ ___ ___		If pregnant, due date: ___ ___			– ___ ___	– ___ ___
Ç Social Security Number						Ç Month	Ç Day	Ç Year
I want to be in:	Blue Cross*	Care 1st*	HealthNet*		Kaiser*	Western Health Advantage*		Regular Medi-Cal (No clinic code needed)
*Doctor or clinic code for your new health plan choice above: ___________________________________

(To ﬁnd the code number, look in the Provider Directory for the plan you choose. It is usually written under the name of your provider. It can also be called a “PCP#” or “Provider Identiﬁcation Number.”)

2nd Applicant
__________________________________			________________________________________				Sex: Male	Female
Ç First Name			Ç Last Name
___ ___ ___	– ___ ___ –	___ ___ ___ ___		If pregnant, due date: ___ ___		– ___ ___	– ___ ___
Ç Social Security Number					Ç Month	Ç Day	Ç Year
I want to be in:	Blue Cross*	Care 1st*	HealthNet*	Kaiser*	Western Health Advantage*		Regular Medi-Cal (No clinic code needed)
*Doctor or clinic code for your new health plan choice above: ___________________________________

3rd Applicant
__________________________________			________________________________________					Sex: Male	Female
Ç First Name			Ç Last Name
___ ___ ___	– ___ ___ –	___ ___ ___ ___		If pregnant, due date: ___ ___			– ___ ___	– ___ ___
Ç Social Security Number						Ç Month	Ç Day	Ç Year
I want to be in:	Blue Cross*	Care 1st*	HealthNet*		Kaiser*	Western Health Advantage*		Regular Medi-Cal (No clinic code needed)

*Doctor or clinic code for your new health plan choice above: ___________________________________

If anyone in your family is changing Medi-Cal Health Plans, please ﬁll in all of the reasons why:				Please ﬁll in
Could not choose desired doctor.	Plan did not meet needs.	Doctor did not meet needs.	Doctor was too far away.
				other side.
Did not choose this plan.	Moving out of the county.
		Other: ______________________________________________________________

Medi-Cal Choice Form Please ﬁll in both sides.

For free help ﬁlling out this form, call 1-800-430-4263.

STATEMENT OF UNDERSTANDING: I understand that by ﬁlling out and signing this form, I am choosing how to get my Medi-Cal health care.

I understand that the Department of Health Care Services will keep the information on this form. They will only use it to enroll or disenroll me from a Medi-Cal Health Plan. Other government agencies that serve Medi-Cal members can also see this information. I can look at the ﬁles that Medi-Cal keeps on me, unless they are being used in an investigation or lawsuit. (To see your Medi-Cal ﬁle, contact the Department of Health Care Services at the address below.)

If You Chose a Medi-Cal Health Plan: I have read the description of the plan I want to join.

If You Join Kaiser: I understand that Kaiser requires binding arbitration. This means that I give up my right to a jury or court trial for medical malpractice and other disagreements about beneﬁts and services. Instead, I would help choose independent professionals who would make a decision about the problem. I can still ask for a Medi-Cal State Hearing.

Please Sign Below:
Head of Household	__________________________________________	Date: ___ ___ – ___ ___	– ___ ___
	Ç Signature	Ç Month Ç Day	Ç Year

1st Applicant
if under 18 years, parent or guardian: __________________________________________	Date:

ÇSignature

2nd Applicant
if under 18 years, parent or guardian: __________________________________________	Date:

ÇSignature

3rd Applicant
if under 18 years, parent or guardian: __________________________________________	Date:

ÇSignature

___ ___ – ___ ___		– ___ ___
Ç Month	Ç Day	Ç Year

___ ___ – ___ ___		– ___ ___
Ç Month	Ç Day	Ç Year

___ ___ – ___ ___		– ___ ___
Ç Month	Ç Day	Ç Year

Mail To:

	California Dept. of Health Services
	Health Care Options
	Box 989009
	Box 989009	Please ﬁll in
	West Sacramento, CA 95798-9850	Please ﬁll in
	West Sacramento, CA 95798-9850	other side.
	________________________________________________________________________________________________________________	other side.

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Provide the requested information in the area Ç Social Security, I want to be in, Blue Cross, Care st, HealthNet, Kaiser, Western Health Advantage, Regular MediCal No clinic code, Doctor or clinic code for your new, rd Applicant, Ç First Name, Ç Last Name, Sex, Male, and Female.

Filling in medical choice form san diego stage 2

In the Head of Household, Date, Ç Signature, Ç Month Ç Day Ç Year, st Applicant if under years, Ç Signature, Ç Month Ç Day Ç Year, nd Applicant if under years, Ç Signature, Ç Month Ç Day Ç Year, rd Applicant if under years, Ç Signature, and Ç Month Ç Day Ç Year field, point out the key data.

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Medical Choice Form – Fill Out and Use This PDF

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