Medical Choice Form PDF Details

Medical Choice Form is a patient-centered medical home (PCMH) model that provides care coordination and support for people living with chronic health conditions. The program helps patients manage their health by connecting them with a care team, including a doctor, nurse, and social worker. Medical ChoiceForm also offers education and resources to help patients manage their condition. If you're looking for an affordable, family-friendly PCMH model, Medical Choice Form may be right for you. To learn more, visit their website or call (844) 462-7463.

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QuestionAnswer
Form NameMedical Choice Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmedical choice form ca, medi cal choice form california, medi cal choice form, medi cal choice form download

Form Preview Example

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: ___________________________________

 

 

(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.”)

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: ___________________________________

(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.”)

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

 

Please fill in

West Sacramento, CA 95798-9850

other side.

________________________________________________________________________________________________________________

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