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." - 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
- 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
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
- 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.