Health Plan Choice Form

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Health Plan Choice Form
California Department of
Health Care Services
P.O. Box 989009
W. Sacramento, CA 95798-9850
For free help filling out this form, call 1-844-580-7272
o
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
or
completely to show your choice.
First Name, Last Name
-
-
___ ___ ___ ___ ___ ___
Address, City
Zip Code
Date of Birth
-
-
(
)
___ ___ ___
___ ___ ___ -___ ___ ___ ___
Sex:
Male
Female
If pregnant, due date
___ ___ ___ ___ ___ ___
(Area Code) Phone Number
Month
Day
Year
Cal MediConnect Plans
Medi-Cal Plans
These plans cover both Medicare & Medi-Cal.
The following plan(s) cover only Medi-Cal.
Pick a health plan from the list below:
Health plan doctor or clinic code. (See instructions)
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
If you are changing your health plan, enter your
If you pick a PACE Plan below, you must also
plan change reason code number.
pick a health plan from
or
above:
(See instructions)
STOP! Read the important information on the back before you sign this form.
I understand that by filling out and signing this form, I am choosing how to get my health care.
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
Highly Confidential
MU_0004000_ENG1_0114

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