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Individual & Family Plans (IFP) Enrollment Applications – Effective January 1, 2022
Ambetter HMO
2022 – Ambetter HMO Enrollment Application - English (PDF)
Ambetter HSP
2022 – Ambetter HSP Enrollment Application - English (PDF)
Ambetter EPO
2022 – Ambetter EPO Enrollment Application - English (PDF)
PPO
2022 – IFP PPO Enrollment Application - English (PDF)
Ambetter PPO
2022 – Ambetter PPO Enrollment Application - English (PDF)
Other Enrollment Forms
Ambetter HMO
- 2022 – Ambetter HMO Quick Start Guide – English (PDF)
- 2022 – Ambetter HMO Quick Start Guide – En Español (Spanish) (PDF)
- 2022 – Ambetter HMO Quick Start Guide – Chinese (PDF)
- 2022 – Ambetter HMO Quick Start Guide – Korean (PDF)
- 2022 – Ambetter HMO Quick Start Guide – Vietnamese (PDF)
Ambetter HSP
- 2022 – Ambetter HSP Quick Start Guide – English (PDF)
- 2022 – Ambetter HSP Quick Start Guide – En Español (Spanish) (PDF)
- 2022 – Ambetter HSP Quick Start Guide – Chinese (PDF)
- 2022 – Ambetter HSP Quick Start Guide – Korean (PDF)
- 2022 – Ambetter HSP Quick Start Guide – Vietnamese (PDF)
Ambetter EPO
- 2022 – Ambetter EPO Quick Start Guide – English (PDF)
- 2022 – Ambetter EPO Quick Start Guide – En Español (Spanish) (PDF)
- 2022 – Ambetter EPO Quick Start Guide – Chinese (PDF)
- 2022 – Ambetter EPO Quick Start Guide – Korean (PDF)
- 2022 – Ambetter EPO Quick Start Guide – Vietnamese (PDF)
PPO
- 2022 – Health Net PPO Quick Start Guide – English (PDF)
- 2022 – Health Net PPO Quick Start Guide – En Español (Spanish) (PDF)
- 2022 – Health Net PPO Quick Start Guide – Chinese (PDF)
- 2022 – Health Net PPO Quick Start Guide – Korean (PDF)
- 2022 – Health Net PPO Quick Start Guide – Vietnamese (PDF)
Ambetter PPO
- 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)
- Preventive Care and Screenings - English (PDF)
- Preventive Care and Screenings - En Español (Spanish) (PDF)
- Wellness Member Guide - English (PDF)
- Wellness Member Guide - En Español (Spanish) (PDF)
- Online Wellness Programs and Resources - English (PDF)
- Online Wellness Programs and Resources - En Español (Spanish) (PDF)
- Wellness Rewards Programs - English (PDF)
- Wellness Rewards Programs - En Español (Spanish) (PDF)
- Wellness Tools - English (PDF)
- Wellness Tools - En Español (Spanish) (PDF)
- Health Coaching Program - English (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)
- Ready to Lose Weight? - English
- Ready to Lose Weight? - En Español (Spanish)
- Quit Smoking - English (PDF)
- Quit Smoking - En Español (Spanish) (PDF)
- Tips to Stop Smoking - English & Spanish (PDF)
- Wellness Webinar Flyer – English (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)
- Out-of-Pocket Maximum Notification - English (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)
Travel Guides
- HMO/POS Travel Guide – English (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.