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Medi Cal Choice 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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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 choice form california, medi cal choice form, 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.

Medical Choice Form – Fill Out and Use

Medi Cal Choice Details

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Medical Choice Form – Fill Out and Use

Medi Cal Choice Details

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