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.
The table holds details about the medical choice form. Our advice is that you check out this material before you decide to begin fiddling with the PDF.
Question | Answer |
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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 |
For free help filling out this form, call
1. Please print. Use a blue or black pen. |
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3. Fill in all information for each person in your household who gets |
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2. Fill in the |
to show your choice. Fill it in completely: |
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4. If you have more than 3 family members, call |
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Head of Household |
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Sex: |
Male |
Female |
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__________________________________ |
________________________________________ |
( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___ |
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Ç First Name |
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Ç Last Name |
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Ç Area Code |
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Ç Telephone or Cell Phone Number |
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____________________________________ ___ ___ ___ ___ ___ |
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Ç Home Address: house number, street name, apartment number |
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Ç City |
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Ç Zip Code |
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1st Applicant |
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Sex: |
Male |
Female |
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Ç First Name |
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Ç Last Name |
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___ ___ ___ |
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If pregnant, due date: ___ ___ |
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Ç Social Security Number |
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Ç Month |
Ç Day |
Ç Year |
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I want to be in: |
Blue Cross* |
Care 1st* |
HealthNet* |
Kaiser* |
Western Health Advantage* |
Regular |
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*Doctor or clinic code for your new health plan choice above: ___________________________________ |
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(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 |
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__________________________________ |
________________________________________ |
Sex: Male |
Female |
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Ç First Name |
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Ç Last Name |
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___ ___ ___ |
– ___ ___ – |
___ ___ ___ ___ |
If pregnant, due date: ___ ___ |
– ___ ___ |
– ___ ___ |
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Ç Social Security Number |
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Ç Month |
Ç Day |
Ç Year |
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I want to be in: |
Blue Cross* |
Care 1st* |
HealthNet* |
Kaiser* |
Western Health Advantage* |
Regular |
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*Doctor or clinic code for your new health plan choice above: ___________________________________ |
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(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 |
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__________________________________ |
________________________________________ |
Sex: Male |
Female |
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Ç First Name |
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Ç Last Name |
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___ ___ ___ |
– ___ ___ – |
___ ___ ___ ___ |
If pregnant, due date: ___ ___ |
– ___ ___ |
– ___ ___ |
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Ç Social Security Number |
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Ç Month |
Ç Day |
Ç Year |
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I want to be in: |
Blue Cross* |
Care 1st* |
HealthNet* |
Kaiser* |
Western Health Advantage* |
Regular |
*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 |
Please fill in |
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Could not choose desired doctor. |
Plan did not meet needs. |
Doctor did not meet needs. |
Doctor was too far away. |
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other side. |
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Did not choose this plan. |
Moving out of the county. |
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Other: ______________________________________________________________ |
For free help filling out this form, call
STATEMENT OF UNDERSTANDING: I understand that by filling out and signing this form, I am choosing how to get my
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
If You Chose a
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
Please Sign Below: |
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Head of Household |
__________________________________________ |
Date: ___ ___ – ___ ___ |
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Ç Signature |
Ç Month Ç Day |
Ç Year |
1st Applicant |
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if under 18 years, parent or guardian: __________________________________________ |
Date: |
ÇSignature
2nd Applicant |
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if under 18 years, parent or guardian: __________________________________________ |
Date: |
ÇSignature
3rd Applicant |
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if under 18 years, parent or guardian: __________________________________________ |
Date: |
ÇSignature
___ ___ – ___ ___ |
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Ç Month |
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Ç Year |
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Ç Month |
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Ç Month |
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Mail To:
California Dept. of Health Services |
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Health Care Options |
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Box 989009 |
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Please fill in |
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West Sacramento, CA |
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other side. |
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