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Individual & Family Plans (IFP) Enrollment Applications –
Effective January 1, 2023
Ambetter HMO
- 2023 – Ambetter HMO Enrollment Application – English (PDF)
- 2023 – Ambetter HMO Enrollment Application – En Español (Spanish) (PDF)
- 2023 – Ambetter HMO Enrollment Application – Chinese (PDF)
- 2023 – Ambetter HMO Enrollment Application – Korean (PDF)
Ambetter PPO
- 2023 – Ambetter PPO Enrollment Application – English (PDF)
- 2023 – Ambetter PPO Enrollment Application – En Español (Spanish) (PDF)
- 2023 – Ambetter PPO Enrollment Application – Chinese (PDF)
- 2023 – Ambetter PPO Enrollment Application – Korean (PDF)
Other Enrollment Forms
- Commercial Medical Claim Form – English (PDF)
- Commercial Medical Claim Form – En Español (Spanish) (PDF)
- Commercial MHN Claim Form – English (PDF)
- IFP Dental Claim Form – English (PDF)
- Out-of-network Vision Claim Form (non-Medicare) – English (PDF)
- Prescription Drug Claim Form – English (PDF)
- Prescription Drug Claim Form – En Español (Spanish) (PDF)
- Essential Pharmacy Benefits Guide – English (PDF)
- Getting Started With Mail Order Pharmacy Kit – English (PDF)
- Getting Started With Mail Order Pharmacy Kit – En Español (Spanish) (PDF)
- Personal Medication List – English (PDF)
- Prescription Drug Claim Form – English (PDF)
- Prescription Drug Claim Form – En Español (Spanish) (PDF)
- Prescription Transition Form – English (PDF)
- Prescription Transition Form – En Español (Spanish) (PDF)
- Pharmacy Maintenance Program Options – English (PDF)
- Pharmacy Maintenance Program Options – En Español (Spanish) (PDF)
- Generic Drugs vs. Brand-Name Drugs – English (PDF)
- Take Medications the Right Way – English (PDF)
- Coverage of Blood Glucose Test Strips – English (PDF)
- Home Infusion Fact Sheet – English (PDF)
- Active&Fit™ Direct Program Flyer – English (PDF)
- Children's Anxiety Flyer – English (PDF)
- CA Wellness Member Brochure – English (PDF)
- CA Wellness Member Brochure – En Español (Spanish) (PDF)
- Healthy Discounts – English (PDF)
- Healthy Discounts – En Español (Spanish) (PDF)
- My Health Pays – English
- My Health Pays – En Español (Spanish)
- myStrength – Personal Support – English (PDF)
- myStrength – Personal Support – En Español (Spanish) (PDF)
- Preventive Screening Guidelines – English (PDF)
- Preventive Screening Guidelines – En Español (Spanish) (PDF)
- Reverse Opioid Overdoses and Help Save Lives with Naloxone – English (PDF)
- Sharecare FAQs – English (PDF)
- Sharecare Craving to Quit – English (PDF)
- Sharecare Diabetes Prevention Program – English (PDF)
- Sharecare Diabetes Prevention Program FAQs – English (PDF)
- Sharecare Health Coaching (Lifestyle Management Flyer) – English (PDF)
- Sharecare RealAge Program Overview – English (PDF)
- Sharecare RealAge Program FAQs – English (PDF)
- Sharecare Green Day Overview – English (PDF)
- Sharecare How to Link Trackers Guide – English (PDF)
- Teladoc Health Member FAQs – English (PDF)
- Teladoc Health Member FAQs – En Español (Spanish) (PDF)
- Teladoc Health Member Flyer – English (PDF)
- Teladoc Health Member Flyer – En Español (Spanish) (PDF)
- Tips to Stop Smoking – English & Spanish (PDF)
- Wellness Tools – English (PDF)
- Wellness Tools – En Español (Spanish) (PDF)
- Wellness Webinar Flyer – English (PDF)
- Wellness Webinar Flyer – En Español (Spanish) (PDF)
- Your Health Coverage Tools – English (PDF)
- ER vs Urgent Care – English (PDF)
- ER vs Urgent Care – En Español (Spanish) (PDF)
- Understanding Health Care Coverage – English (PDF)
- Understanding Health Care Coverage – En Español (Spanish) (PDF)
- Continuity of Care Assistance Request Form – English (PDF)
- Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
- How Soon Can I See the Doctor? – English (PDF)
- How Soon Can I See the Doctor? – En Español (Spanish) (PDF)
- MinuteClinic Brochure – English (PDF)
- MinuteClinic Brochure – En Español (Spanish) (PDF)
- Home Infusion Fact Sheet – English (PDF)
Travel Guides
- HMO Travel Guide – English (PDF)
- HMO Travel Guide – En Español (Spanish) (PDF)
- PPO Travel Guide – English (PDF)
- PPO Travel Guide – En Español (Spanish) (PDF)
Department of Managed Health Care (DMHC)
Compliance Forms
- Authorization for Disclosure of Protected Health Information – English (PDF)
- Authorization for Disclosure of Protected Health Information – En Español (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 – En Español (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.