Health Plan Choice Form

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Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
California Department of
California Department of
California Department of
Health Plan Choice Form
California Department of
California Department of
California Department of
California Department of
Health Care Services
Health Care Services
Health Care Services
Health Care Services
Health Care Services
Health Care Services
Health Care Services
P.O. Box 989009
P.O. Box 989009
P.O. Box 989009
P.O. Box 989009
P.O. Box 989009
P.O. Box 989009
P.O. Box 989009
W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
For free help filling out this form, call 1-844-580-7272
For free help filling out this form, call 1-844-580-7272
For free help filling out this form, call 1-844-580-7272
If you do not want to automatically enroll in the Cal MediConnect plan we have chosen for you, use this form
If you do not want to automatically enroll in the Cal MediConnect plan we have chosen for you, use this form
If you do not want to automatically enroll in the Cal MediConnect plan we have chosen for you, use this form
If you do not want to automatically enroll in the Cal MediConnect plan we have chosen for you, use this form
to choose a different option. For Free Help with this form, contact Health Care Options at 1-844-580-7272.
o
to choose a different option. For Free Help with this form, contact Health Care Options at 844-580-7272.
o
to choose a different option. For Free Help with this form, contact Health Care Options at 844-580-7272.
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
or
completely to show your choice.
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
or
o
completely to show your choice.
to choose a different option. For Free Help with this form, contact Health Care Options at 844-580-7272.
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
or
completely to show your choice.
Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
Health Plan Choice Form
California Department of
California Department of
California Department of
California Department of
California Department of
California Department of
Health Care Services
Health Care Services
Health Care Services
Health Care Services
STEP 1: Tell us about yourself:
Health Care Services
Health Care Services
STEP 1: Tell us about yourself:
STEP 1: Tell us about yourself:
STEP 1: Tell us about yourself:
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P.O. Box 989009
P.O. Box 989009
P.O. Box 989009
P.O. Box 989009
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P.O. Box 989009
P.O. Box 989009
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JOHN SAMPLE
W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
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W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
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W. Sacramento, CA 95798-9850
W. Sacramento, CA 95798-9850
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First Name, Last Name
Social Security Number
First Name, Last Name
Social Security Number
First Name, Last Name
Social Security Number
First Name, Last Name
First Name, Last Name
First Name, Last Name
Social Security Number
First Name, Last Name
Social Security Number
Social Security Number
For free help filling out this form, call 1-844-580-7272
For free help filling out this form, call 1-844-580-7272
Social Security Number
For free help filling out this form, call 1-844-580-7272
For free help filling out this form, call 1-844-580-7272
For free help filling out this form, call 1-844-580-7272
For free help filling out this form, call 1-844-580-7272
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9
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9 9
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1234 SAMPLE STREET SAMPLE CITY
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Address, City
Zip Code
Date of Birth
Address, City
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Zip Code
Date of Birth
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Address, City
Zip Code
Date of Birth
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
or
or
completely to show your choice.
completely to show your choice.
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
or
or
o
o
completely to show your choice.
completely to show your choice.
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
Please print all CAPITAL LETTERS. Use a blue or black pen. Fill in the
or
or
completely to show your choice.
completely to show your choice.
Address, City
Zip Code
Date of Birth
Address, City
Zip Code
Date of Birth
Address, City
Zip Code
Date of Birth
Address, City
Zip Code
Date of Birth
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Sex:
Male
Female
If pregnant, due date
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Sex:
Male
Female
If pregnant, due date
___ ___ ___
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___ ___ ___ ___
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If pregnant, due date
Sex:
Male
Female
___ ___ ___
___ ___ ___
___ ___ ___ ___
___ ___
___ ___
___ ___
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(
)
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(
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(
)
If pregnant, due date
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Sex:
Male
Female
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___ ___ ___
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___ ___ ___ ___
Sex:
Male
Female
If pregnant, due date
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(
___ ___ ___
)
___ ___ ___
___ ___ ___ ___
Sex:
Male
Female
If pregnant, due date
___ ___
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___ ___
___ ___ ___
___ ___ ___
___ ___ ___ ___
___ ___
___ ___
___ ___
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If pregnant, due date
(Area Code) Phone Number
Sex:
Male
Female
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(Area Code) Phone Number
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Month
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Day
Year
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Month
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Day
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Year
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(Area Code) Phone Number
Month
Day
Year
(Area Code) Phone Number
(Area Code) Phone Number
Month
Day
Year
(Area Code) Phone Number
Month
Day
Year
Month
Day
Year
(Area Code) Phone Number
First Name, Last Name
First Name, Last Name
Social Security Number
Social Security Number
Month
Day
Year
First Name, Last Name
First Name, Last Name
Social Security Number
Social Security Number
First Name, Last Name
First Name, Last Name
Social Security Number
Social Security Number
PLEASE READ the Instructions and Guidebook before completing this form.
PLEASE READ the Instructions and Guidebook before completing this form.
PLEASE READ the Instructions and Guidebook before completing this form.
STEP 2: Choose how you want your care:
STEP 2: Choose how you want your care:
STEP 2: Choose how you want your care:
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STEP 2: Choose how you want your care:
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Cal MediConnect Plans:
Medi-Cal Plans:
Cal MediConnect Plans:
Medi-Cal Plans:
Cal MediConnect Plans:
Medi-Cal Plans:
If you do NOT make a choice, you will be automatically enrolled in a Cal MediConnect Plan we have chosen for you.
If you do not make a choice, you will be automatically enrolled in a Cal MediConnect Plan we have chosen for you.
If you do not make a choice, you will be automatically enrolled in a Cal MediConnect Plan we have chosen for you.
If you do not make a choice, you will be automatically enrolled in a Cal MediConnect Plan we have chosen for you.
Address, City
Address, City
Zip Code
Zip Code
Date of Birth
Date of Birth
Address, City
Address, City
Zip Code
Zip Code
Date of Birth
Date of Birth
Address, City
Address, City
Zip Code
Zip Code
Date of Birth
Date of Birth
OR
OR
OR
OPTION A
OPTION A
OPTION B
OPTION A
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OPTION B
OR
OPTION B
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OPTION A
OPTION B
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Sex:
Sex:
Male
Male
Female
Female
If pregnant, due date
If pregnant, due date
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(
(
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)
)
___ ___ ___
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___ ___ ___ ___
___ ___ ___ ___
Sex:
Sex:
Male
Male
Female
Female
If pregnant, due date
If pregnant, due date
___ ___ ___
___ ___ ___
___ ___ ___
___ ___ ___
___ ___ ___ ___
___ ___ ___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
___ ___
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Sex:
Sex:
Male
Male
Female
Female
If pregnant, due date
If pregnant, due date
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Combine my Medicare and Medi-Cal benefits in
Keep my Medicare the way it is now AND choose a
Combine my Medicare and Medi-Cal benefits in
Combine my Medicare and Medi-Cal benefits in
Keep my Medicare the way it is now AND choose a
Keep my Medicare the way it is now AND choose a
(Area Code) Phone Number
(Area Code) Phone Number
(Area Code) Phone Number
(Area Code) Phone Number
Month
Month
Day
Day
Year
Year
Combine my Medicare and Medi-Cal benefits in
Keep my Medicare the way it is now AND choose a
Month
Month
Day
Day
Year
Year
(Area Code) Phone Number
(Area Code) Phone Number
Month
Month
Day
Day
Year
Year
one plan.
one plan.
one plan.
Medi-Cal plan.
Medi-Cal plan.
Medi-Cal plan.
one plan.
Medi-Cal plan.
PLEASE READ the Instructions and Guidebook before completing this form.
PLEASE READ the Instructions and Guidebook before completing this form.
PLEASE READ the Instructions and Guidebook before completing this form.
PLEASE READ the Instructions and Guidebook before completing this form.
PLEASE READ the Instructions and Guidebook before completing this form.
PLEASE READ the Instructions and Guidebook before completing this form.
Choose one of these Cal MediConnect Plans:
Choose one of these Medi-Cal Plans to get your
Choose one of these Cal MediConnect Plans:
Choose one of these Cal MediConnect Plans:
Choose one of these Medi-Cal Plans to get your
Choose one of these Medi-Cal Plans to get your
Choose one of these Cal MediConnect Plans:
Choose one of these Medi-Cal Plans to get your
Medi-Cal benefits:
Medi-Cal benefits:
Medi-Cal benefits:
Cal MediConnect Plans:
Cal MediConnect Plans:
Medi-Cal Plans:
Medi-Cal Plans:
Cal MediConnect Plans:
Cal MediConnect Plans:
Medi-Cal Plans:
Medi-Cal Plans:
Medi-Cal benefits:
Cal MediConnect Plans:
Cal MediConnect Plans:
Medi-Cal Plans:
Medi-Cal Plans:
*
Health plan doctor or clinic code. (See instructions)
Health plan doctor or clinic code. (See instructions)
Health plan doctor or clinic code. (See instructions)
* To choose the plan that you have been assigned to,
* To choose the plan that you have been assigned to,
* To choose the plan that you have been assigned to,
* To choose the plan that you have been assigned to,
select the plan with the asterisk (*).
select the plan with the asterisk (*).
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
select the plan with the asterisk (*).
select the plan with the asterisk (*).
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
PACE (Program of the All-Inclusive Care for the Elderly:
PACE (Program of the All-Inclusive Care for the Elderly:
If you are changing your health plan, enter your
PACE Plan:
PACE Plan:
PACE Plan:
If you are changing your health plan, enter your
PACE Plan:
Program of the All-Inclusive Care for the Elderly (PACE):
PACE (Program of the All-Inclusive Care for the Elderly:
PACE Plan:
If you are changing your health plan, enter your
PACE Plan:
PACE Plan:
You may qualify for PACE (see instructions). If you want to get
You may qualify for PACE (see instructions). If you want to get
You may qualify for PACE (see instructions). If you want to get
plan change reason code number.
You may qualify for PACE (see instructions). If you want to get
plan change reason code number.
plan change reason code number.
your Medicare and Medi-Cal benefits combined in a PACE
your Medicare and Medi-Cal benefits combined in a PACE
your Medicare and Medi-Cal benefits combined in a PACE plan,
your Medicare and Medi-Cal benefits combined in a PACE
(See instructions)
(See instructions)
(See instructions)
plan, fill out this option in addition to Option A or B.
plan, fill out this option in addition to Option A or B.
Health plan doctor or clinic code. (See instructions)
Health plan doctor or clinic code. (See instructions)
Health plan doctor or clinic code. (See instructions)
Health plan doctor or clinic code. (See instructions)
fill out this option in addition to Option A or B.
plan, fill out this option in addition to Option A or B.
Health plan doctor or clinic code. (See instructions)
Health plan doctor or clinic code. (See instructions)
If you do not qualify, you will get your care through the
If you do not qualify, you will get your care through the
If you do not qualify, you will get your care through the
If you do not qualify, you will get your care through the
___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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___ ___ ___ ___ ___ ___ ___ ___ ___ ___
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STOP! Read the important information on the back before you sign this form.
STOP! Read the important information on the back before you sign this form.
Option A or Option B plan that you chose above in Step 2.
Option A or Option B plan that you chose above in Step 2.
Option A or Option B plan that you chose above in Step 2.
STOP! Read the important information on the back before you sign this form.
Option A or Option B plan that you chose above in Step 2.
I understand that by filling out and signing this form, I am choosing how to get my health care.
I understand that by filling out and signing this form, I am choosing how to get my health care.
If you are changing your health plan, enter your
If you are changing your health plan, enter your
PACE Plan:
PACE Plan:
If you are changing your health plan, enter your
If you are changing your health plan, enter your
I understand that by filling out and signing this form, I am choosing how to get my health care.
PACE Plan:
PACE Plan:
If you are changing your health plan, enter your
If you are changing your health plan, enter your
PACE Plan:
PACE Plan:
STEP 3: Read the important information on the back before signing. I understand that by filling out and signing this
STEP 3: Read the important information on the back before signing.
STEP 3: Read the important information on the back before signing.
STEP 3: Read the important information on the back before signing.
plan change reason code number.
plan change reason code number.
plan change reason code number.
plan change reason code number.
form, I am choosing how to get my health care.
plan change reason code number.
plan change reason code number.
(See instructions)
(See instructions)
(See instructions)
(See instructions)
(See instructions)
(See instructions)
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
Beneficiary’s signature
Date
OR
Authorized Representative Signature (if any) Date
STOP! Read the important information on the back before you sign this form.
STOP! Read the important information on the back before you sign this form.
STOP! Read the important information on the back before you sign this form.
STOP! Read the important information on the back before you sign this form.
STOP! Read the important information on the back before you sign this form.
STOP! Read the important information on the back before you sign this form.
Highly Confidential
Highly Confidential
Highly Confidential
Highly Confidential
Highly Confidential
Highly Confidential
Highly Confidential
MU_0004000_ENG1_0214
MU_0004000_ENG1_0214
MU_0004000_ENG1_0714 (070814)
MU_0004000_ENG1_0714 (070814)
MU_0004000_ENG1_0214
MU_0004000_ENG1_0714 (070814)
I understand that by filling out and signing this form, I am choosing how to get my health care.
I understand that by filling out and signing this form, I am choosing how to get my health care.
I understand that by filling out and signing this form, I am choosing how to get my health care.
I understand that by filling out and signing this form, I am choosing how to get my health care.
MU_0004000_ENG1_0714
I understand that by filling out and signing this form, I am choosing how to get my health care.
I understand that by filling out and signing this form, I am choosing how to get my health care.

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