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Month Day Year
Health Plan Choice Form
California Department of
Health Care Services
P.O. Box 989009
W. Sacramento, CA 95798-9850
CCIOB
For Free Help with this form, contact Health Care Options at 1-844-580-7272.
STEP 1: Tell us about yourself:
First Name, Last Name
Social Security Number
Address, City Zip Code Date of Birth
(Area Code) Phone Number
Sex: Male Female
If pregnant, due date
STEP 2: Choose how you want your care:
OPTION A
Combine my Medicare and Medi-Cal benets in
one plan.
Choose one of these Cal MediConnect Plans:
803
Blue Shield Promise
804
CommuniCare Advantage
805
Health Net
806
Molina DualOptions
OR
OPTION B
Keep my Medicare the way it is now AND choose a
Medi-Cal plan.
Choose one of these Medi-Cal Plans to get your
Medi-Cal benets:
029
CommunityHlthGrpPartner
068
HealthNetCommSolutions
079
KP Cal, LLC
131
Molina Healthcare Partner
167
Blue Shield Promise
Additional Health Plan Option- Program of All-inclusive Care for the Elderly (PACE)
If you are 55 or older and need a higher level of care to live at home, you may be able to join PACE. PACE provides all
Medicare and Medi-Cal benets plus extra services to help seniors who have chronic conditions live at home. For more
information and to determine if you live in an area served by PACE visit: www.calpace.org.
STEP 3: Read the important information on the back before signing. I understand that by lling out and signing this
form, I am choosing how to get my health care.
Beneciarys signature Date OR Authorized Representative Signature (if any) Date
SD_0004100_ENG1_0615
Highly Condential
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signature
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signature
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Health Plan Choice Form
California Department of
Health Care Services
P.O. Box 989009
W. Sacramento, CA 95798-9850
Read this important information before you sign the form.
If I Join the Medi-Cal KP Cal, LLC (Kaiser Permanente):
I understand that Kaiser requires binding arbitration
for my Medi-Cal benets. This means that I give up my
right to a jury or court trial for medical malpractice
and other disagreements about benets and services.
Instead, I would help choose independent professionals
who would make a decision about the problem. I can
still ask for a Medi-Cal State Hearing.
By completing this enrollment application for a
Cal MediConnect plan or by allowing the State to
enroll me in a Cal MediConnect plan, I agree to the
following:
Cal MediConnect plans are Medicare-Medicaid plans
that have a contract with the State of California and
the Federal government. I will need to keep my
Medicare Parts A and B and Medi-Cal. I can be in only
one Medicare plan at a time, and I understand that my
enrollment in the plan selected will automatically end
my enrollment in any other Medicare health plan or
Medicare prescription drug plan.
I understand that prescription drugs are covered,
but not always the same ones I’m already taking.
I understand that I’ll be able to receive at least one
30-day supply of the prescription drugs I currently take
anytime during the rst 90 days of coverage in a
Cal MediConnect Plan. I understand that I may be able
to continue seeing the doctors I go to now for a period
up to six (6) months for Medicare services and a period
of up to twelve (12) months for Medi-Cal services from
the eective date of enrollment in a Cal MediConnect
Plan. I must contact the Cal MediConnect Plan for
information on how to do this. I further understand
that the Cal MediConnect Plan has providers and
pharmacies that I must use to get health care services,
except for non-routine, emergency situations.
Cal MediConnect plans serve a specic service area.
If I move out of the area covered by the plan chosen,
I need to notify the plan so I can disenroll and nd a
new plan in my new area.
I understand that beginning on the date my Cal
MediConnect coverage begins, I must get all of my
health care from my new plan, except for emergency
or urgently needed services or out-of-area dialysis
services. Services authorized by my Cal MediConnect
plan and other services contained in my plan's
Evidence of Coverage document will be covered.
Without authorization, NEITHER Medicare, Medi-Cal
NOR my Cal MediConnect plan WILL PAY FOR THE
SERVICES.
Release of Information: By joining this Medicare
and Medicaid plan, I acknowledge that the plan I
selected will release my information to Medicare and
other plans as is necessary for treatment, payment
and health care operations. I also acknowledge that
my Cal MediConnect plan will release my information,
including my prescription drug event data, to Medicare,
who may release it for research and other purposes
which follow all applicable Federal statutes and
regulations. The information on this enrollment form is
correct to the best of my knowledge. I understand that
if I intentionally provide false information on this form,
I will be disenrolled from the plan.
I understand that my signature (or the signature of
the person authorized to act on my behalf under the
laws of California on this application) means that I've
read and understand the contents of this application.
If signed by an authorized individual, this signature
certies: 1) this person is authorized under State law to
complete this enrollment and 2) documentation of this
authority is available upon request from Medicare.
Privacy Statement
The Department of Health Care Services will keep the information you provide. It is used only to enroll and/
or disenroll people that are eligible for Medi-Cal managed care. The laws that allow this are in the Welfare and
Institutions Code, Section 10416.5, 14016.6, 14087.305, 14087.31, 14087.35, 14087.36, 14087.38, 14087.96,
14088, 14089, 14089.5, and 14631, and California Code of Regulations, Section 51085.5.
Only other government agencies that relate to the Medi-Cal program can see the information you provide.
However, any information that is being used in an investigation or lawsuit cannot be seen. If you want to see
your Medi-Cal le, contact the Department of Health Care Services at the address on the other side of this form.
MU_0004100_ENG2_0615
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