Forms and Brochures
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2019 Forms and Brochures
Enrollment applications
HMO
HSP
EPO
PPO
EnhancedCare PPO
Other Enrollment Forms
- Hardship Exemption Form
*Please choose the document from the third bullet under "Step 1: Identify the correct form for you."
- 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)
Travel Guides
Department of Managed Health Care (DMHC)
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)
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.
2018 Forms and Brochures
Enrollment applications
HMO
- IFP CommunityCare HMO Enrollment Application - English (PDF)
- IFP CommunityCare HMO Enrollment Application - Spanish (PDF)
- IFP CommunityCare HMO Enrollment Application - Chinese (PDF)
- IFP CommunityCare HMO Enrollment Application - Korean (PDF)
HSP
- IFP PureCare HSP Enrollment Application - English (PDF)
- IFP PureCare HSP Enrollment Application - Spanish (PDF)
- IFP PureCare HSP Enrollment Application - Chinese (PDF)
- IFP PureCare HSP Enrollment Application - Korean (PDF)
EPO
- IFP PureCare One EPO Enrollment Application - English (PDF)
- IFP PureCare One EPO Enrollment Application - Spanish (PDF)
- IFP PureCare One EPO Enrollment Application - Chinese (PDF)
- IFP PureCare One EPO Enrollment Application - Korean (PDF)
PPO
- IFP PPO Enrollment Application - English (PDF)
- IFP PPO Enrollment Application - Spanish (PDF)
- IFP PPO Enrollment Application - Chinese (PDF)
- IFP PPO Enrollment Application - Korean (PDF)
EnhancedCare PPO
- IFP EnhancedCare PPO Enrollment Application - English (PDF)
- IFP EnhancedCare PPO Enrollment Application - Spanish (PDF)
- IFP EnhancedCare PPO Enrollment Application - Chinese (PDF)
- IFP EnhancedCare PPO Enrollment Application - Korean (PDF)
Other Enrollment Forms
- 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)
Travel Guides
Department of Managed Health Care (DMHC)
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.