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You print, use a blue or black pen, and fill in both sides.
Household: fill in all information for each person in your household who gets Medi-Cal.
Family members: if you have more than 3 family members, call 1-800-430-4263 to ask for another form.
Changing plans: if anyone in your family is changing Medi-Cal Health Plans, please fill in all of the reasons why.
Kaiser: if you join Kaiser, you give up your right to a jury or court trial for medical malpractice and other disagreements about benefits and services.
| Question | Answer |
|---|---|
| Form Name | Medi-Cal Choice Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 6 min |
| Where to send | California Dept. of Health Services, Health Care Options, Box 989009, West Sacramento, CA 95798-9850 |
| Other names | Medi-Cal Choice Form, Medi Cal choice form, choice form |
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