Mail form back to: California Department of Health Care Services
Medi-Cal Choice Form
P.O. Box 989009 • W. Sacramento, CA 95798-9850
Use this form to join or change plans. For help, call 1-800-430-4263.
Please print. Fill in the ovals to indicate your choice.
1) Head of Household Name (First Name) 2) Last Name
3) Home Address (House Number, Street Name, Apartment Number)
4) City 5) Zip Code 6) Area Code & Phone Number
7) E-mail Address
8) Applicant's Name (First Name) 9) Last Name
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/ /
Male
10) Sex Female 11) Due Date (if pregnant) 12) Birth Year 13) Social Security Number
14) I wish to JOIN or change my plan to:
15) Doctor/Clinic Code Internal Use
16) Fill in the oval next to the reason for changing your plan.
Moving out of the county
The plan did not meet my needs
I could not choose the doctor I wanted
Indian Health Program Exemption
My doctor did not meet my needs
Exempt from a plan
Too far to go
Other
I did not choose this plan
Notice: I have read the plan description. I understand that Kaiser requires the use of binding neutral
arbitration to resolve certain disputes. This includes disputes about whether the right medical treatment
was provided (called medical malpractice) and other disputes relating to benets or the delivery of services.
If I pick Kaiser, I give up my right to a jury or court trial for those certain disputes. I also agree to use binding
neutral arbitration to resolve those certain disputes. I do not give up my right to a State hearing of any issue,
which is subject to the State hearing process.
Choice Statement: I/We have made written choice to receive Medi-Cal benefits through the plans as
I/we have indicated on this form. I/We have read and understand the conditions of this agreement.
I/We understand that in order to change my/our current Medi-Cal plan, I/we must complete this form.
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HCOOMBA
Head of Household or Authorized Representative Signature Date
Highly Condential
AL_0VM3451_ENG_0617
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