Forms and Brochures

• Commerical Medical Claim Form - English (PDF)
• Commerical Medical Claim Form - Spanish (PDF)

• IFP Dental Claim Form (PDF)

• Out-of-network Vision Claim Form (non-Medicare) (PDF)

• Prescription Drug Claim Form - English (PDF)
• Prescription Drug Claim Form - Spanish (PDF)

Enrollment applications

HMO

• IFP CommunityCare HMO Enrollment Application - English (PDF)

HSP

• IFP PureCare HSP Enrollment Application - English (PDF)

EPO

• IFP PureCare One EPO Enrollment Application - English (PDF)

PPO

• IFP PPO Enrollment Application - English (PDF)

EnhancedCare PPO

• IFP EnhancedCare PPO Enrollment Application - English (PDF)

Other Enrollment Forms

• Hardship Exemption Form
  *Please choose the document from the third bullet under "Step 1: Identify the correct form for you."

• HSA for Life - Enrollment Packet (PDF)

• Essential Pharmacy Benefits Guide - English (PDF)

• Getting Started With Mail Order Pharmacy Kit - English (PDF)
• Getting Started With Mail Order Pharmacy Kit - Spanish (PDF)

• Personal Medication List (PDF)

• Prescription Drug Claim Form - English (PDF)
• Prescription Drug Claim Form - Spanish (PDF)

• Prescription Transition Form - English (PDF)
• Prescription Transition Form - Spanish (PDF)

• Pharmacy Maintenance Program Options - English (PDF)
• Pharmacy Maintenance Program Options - Spanish (PDF)

Directories

• CA Standard Pharmacy Directory - English (PDF)
• CA Advanced Choice Pharmacy Directory - English (PDF)

• Preventive Care and Screenings - English (PDF)
• Preventive Care and Screenings - Spanish (PDF)

• Online Wellness Programs and Resources - English (PDF)
• Online Wellness Programs and Resources - Spanish (PDF)

• Wellness Rewards Programs - English (PDF)
• Wellness Rewards Programs - Spanish (PDF)

• Wellness Menu - English (PDF)
• Wellness Menu - Spanish (PDF)

• Healthy Discounts - English (PDF)
• Healthy Discounts - Spanish (PDF)

• myStrength - personal support - English (PDF)
• myStrength - personal support - Spanish (PDF)

• Health Coaching Program - English (PDF)

• Ready to Lose Weight? - English (PDF)
• Ready to Lose Weight? - Spanish (PDF)

• Quit Smoking - English (PDF)
• Quit Smoking - Spanish (PDF)

• Text4Baby - English (PDF)
• Text4Baby - Spanish (PDF)

• Your Health Coverage Tools (PDF)
• ER vs Urgent Care (PDF)
• Understanding Health Care Coverage - English (PDF)
• Understanding Health Care Coverage - Spanish (PDF)

• Continuity of Care Assistance Request Form - English (PDF)
• Continuity of Care Assistance Request Form - Spanish (PDF)

• Out-of-Pocket Maximum Notification (PDF)
  

• How Soon Can I See the Doctor? (PDF)

Travel Guides

• HMO/POS Travel Guide - English (PDF)
• HMO/POS Travel Guide - Spanish (PDF)

• PPO Travel Guide (PDF)

Department of Managed Health Care (DMHC)

• Right to Submit Request for Review of Cancellation, Rescission, or Nonrenewal of Your Plan Contract, Enrollment, or Subscription (PDF)

• Request for Review of Cancellation, Rescission, or Nonrenewal of Plan Contract (PDF)

CommunityCare HMO

CommunityCare HMO Quick Start Guide - English (PDF)
CommunityCare HMO Quick Start Guide - Spanish (PDF)
CommunityCare HMO Quick Start Guide - Chinese (PDF)
CommunityCare HMO Quick Start Guide - Korean (PDF)
CommunityCare HMO Quick Start Guide - Vietnamese (PDF)

PureCare HSP

PureCare HSP Quick Start Guide - English (PDF)
PureCare HSP Quick Start Guide - Spanish (PDF)
PureCare HSP Quick Start Guide - Chinese (PDF)
PureCare HSP Quick Start Guide - Korean (PDF)
PureCare HSP Quick Start Guide - Vietnamese (PDF)

Purecare EPO

PureCare One EPO Quick Start Guide - English (PDF)
PureCare One EPO Quick Start Guide - Spanish (PDF)
PureCare One EPO Quick Start Guide - Chinese (PDF)
PureCare One EPO Quick Start Guide - Korean (PDF)
PureCare One EPO Quick Start Guide - Vietnamese (PDF)

PPO

Health Net PPO Quick Start Guide - English (PDF)
Health Net PPO Quick Start Guide - Spanish (PDF)
Health Net PPO Quick Start Guide - Chinese (PDF)
Health Net PPO Quick Start Guide - Korean (PDF)
Health Net PPO Quick Start Guide - Vietnamese (PDF)

EnhancedCare PPO

EnhancedCare PPO Quick Start Guide - English (PDF)
EnhancedCare PPO Quick Start Guide - Spanish (PDF)
EnhancedCare PPO Quick Start Guide - Chinese (PDF)
EnhancedCare PPO Quick Start Guide - Korean (PDF)
EnhancedCare PPO Quick Start Guide - Vietnamese (PDF)

• Acupuncturists (Statewide) - English (PDF)
• Chiropractors (Statewide) - English (PDF)
• Health Net Vision - Part 1 (Statewide) - English (PDF)
• Health Net Vision - Part 2 (Statewide) - English (PDF)
• Dental HMO (North) - English (PDF)
• Dental HMO (South) - English (PDF)
• Dental PPO (North) - English (PDF)
• Dental PPO (South) Region A - English (PDF)
• Dental PPO (South) Region B (Part 1) - English (PDF)
• Dental PPO (South) Region B (Part 2) - English (PDF)

Compliance Forms

• Authorization for Disclosure of Protected Health Information - English (PDF)
• Authorization for Disclosure of Protected Health Information - Spanish (PDF)
• Authorization for Disclosure of Protected Health Information - Chinese (PDF)
• Authorization for Disclosure of Protected Health Information - Korean (PDF)

• Glossary of Health Coverage and Medical Terms - English (PDF)
• Glossary of Health Coverage and Medical Terms - Spanish (PDF)
• Glossary of Health Coverage and Medical Terms - Chinese (PDF)
• Glossary of Health Coverage and Medical Terms - Korean (PDF)
• Glossary of Health Coverage and Medical Terms - Navajo (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.