Health PlanChoice Choice Form Health Plan Plan Choice Form Health Form CaliforniaDepartment Departmentof of California Department of Department of California California Department of California Department of Services Health Care Care Services Services Health Health Care Services P.O. Box 989009 P.O. Box 989009 P.O. Box Box 989009 989009 P.O. P.O. Box 989009 Box 989009 W.Sacramento, Sacramento,P.O. CA95798-9850 95798-9850 W. Sacramento, CA 95798-9850 CA 95798-9850 W. CA W. Sacramento, CA 95798-9850 W. Sacramento, CA 95798-9850 free help form, call 1-844-580-7272 For free help filling filling out this form, callplan 1-844-580-7272 CCIPA If you do notnot wantFor to automatically enroll inout the this Calthe MediConnect we have we chosen forchosen you, use this form this CCIPA If form CCIPA If you you do do not want want to to automatically automatically enroll enroll in in the Cal Cal MediConnect MediConnect plan plan we have have chosen for for you, you, use use this form toPlease choose a different option. For Free Help with this form, contact Health Care Options at 1-844-580-7272. to choose a different option. For Free Help with this form, contact Health Care Options at 844-580-7272. print all CAPITAL LETTERS. Use a blue or black pen. Fill in the  or o completely to show your choice. to choose differentLETTERS. option. For Free Helporwith this form, Health Care Options 844-580-7272. Please print alla CAPITAL Use a blue black pen. Fillcontact in the  or oCalifornia completely toatshow California Department Department of of California California Department Department of of your choice. *CCIPA* Health Health Plan Plan Choice Choice Form Form California California Department Department of of Health Health Care Services Health Health Care Care Care Services Services Services - STEP 1: STEP 1: Tellus us about about yourself: yourself: STEP 1: Tell Tell us about yourself: JOHN SAMPLE P.O. P.O. Box 989009 989009 P.O. P.O.Box Box Box 989009 989009 ---___ P.O. P.O. Box Box 989009 989009 ___ ___ ___ ___ ___ ___ ___ ___ ___ -___ ___ ___ ___ ___ ___ ___ ___ -___ ___ ___ ___ ___ ___ ___ ___ ___ W. W. Sacramento, CA CA 95798-9850 95798-9850 W. W.Sacramento, Sacramento, Sacramento, CA CA 95798-9850 95798-9850 W. W. Sacramento, Sacramento, CA CA 95798-9850 95798-9850 ___ ___ ___- ___ ___--- ___ ___ ___ ___ JOHN SAMPLE SAMPLE JOHN JOHN SAMPLE *M-0-XXXXXXXXX-H* For free free help filling filling out out this form, call 1-844-580-7272 -- *CCIPA* -99999 *CCIPA* 1234 STREET SAMPLE CITY For For free free help help help filling filling out out this this this form, form, form, call call call 1-844-580-7272 1-844-580-7272 1-844-580-7272 99999 1234 SAMPLE SAMPLEFor STREET SAMPLE CITY ___ ___ ___ ___ ___----___ ___ ___----___ ___ ___ ___ 9 9 9 9 9 ___ ___ ___ ___ ___ ___ 1234 SAMPLE STREET SAMPLE CITY - ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ M-XXXXXXXXX-H M-XXXXXXXXX-H ___ ___ ___ ___ ___ ___ ___ ___ ___ Social Security Number M-XXXXXXXXX-H Social Security Number Social Security Number Social Security Number Social Security Number Social Security Security Number Number Social  Last First Name, Name, Last Name Name  First First Name, Last Name First Name, Last First Name, Last First Name, LastName Name First Name, Last Name CCIPA CCIPA CCIPA CCIPA CCIPA CCIPA ______ ___ ___of ___ ______ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Address, Zip Date Birth Address, City City Zip Code Code Date of Birth ___ ___ ___ ___ ___ ___ Address, City Zip Code Date of Birth Please Please print print all all CAPITAL CAPITAL LETTERS. LETTERS. Use Use a a blue blue or or black black pen. pen. Fill Fill in in the the   or or o o completely completely to to show show your your choice. choice. Please Please print print all all CAPITAL CAPITAL LETTERS. LETTERS. Use Use a a blue blue or or black black pen. pen. Fill Fill in in the the   or or o o completely completely to to show show your your choice. choice. Address, City Zip Code Date of Birth Address, City Zip Code Date of Birth Address, City City Zip Code Code Date of of Birth Birth Address, Zip Date ---((___  If pregnant, due date ___ ___ ___ ___ ___ ___)) ___ ___ ___ ___ ___ ___---___ ___ ___ ___ ___ ___ ___ ___ Sex:  Male  Female ___ ___ ___----___ ___ ___ ___---___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___  If pregnant, due date ___ ___ ___ ___ ___ Sex:  Male  Female -___ -___ ((((Area ___ ___ ))) ___ ___ ___ ___ ___ pregnant, due date ______ ___--___ ___ ___ ___ ___ Female Female ___ ___ ___ ___ If due date ______ ___ ___ ___Number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Sex: -___ ___ ___ ___ ___ ___ ___ JOHN JOHN SAMPLE SAMPLE Code) Phone ___ ___ ___ Month Day Year (Area Code) Phone Number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___--___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Month Day Year ___ ___ ___ ___ IfIfpregnant, pregnant, due date Sex:  Male Male   Female JOHN JOHN SAMPLE SAMPLE (Area Code) Phone Number ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Month Day Year *M-0-XXXXXXXXX-H* *M-0-XXXXXXXXX-H* Month Number Day Year Year *M-0-XXXXXXXXX-H* Month Day Month Day Year Social Security Month Day Year Social Social Security Security Number Number Social Social Security Security Number Number (Area Code) Phone Number (Area Code) Phone (Area Code) Phone Number (Area Code) Phone   Name, Last Name First First Name, Name, Last LastNumber Name Name   First First First Name, Name, Last Last Name Name MM-XXXXXXXXX-H MM- -XXXXXXXXX-H -XXXXXXXXX-H -XXXXXXXXX-H MM-XXXXXXXXX-H -XXXXXXXXX-H PLEASE PLEASE READ READ the the Instructions Instructions and and Guidebook Guidebook before before completing completing this this form. form. Sa Fo m rm ple C o H nt e fo al ac t r t h in fu fo rt C rm he ar e at r O io p n. tio n s ----STEP 2: Choose you STEP 2: your care: 99999 99999 Choose how how you want want 1234 1234 SAMPLE STREET STREET SAMPLE SAMPLE CITY STEP 2:SAMPLE Choose how you want yourCITY care: 99999 99999 ___ 1234 1234 SAMPLE SAMPLE STREET STREET SAMPLE SAMPLE CITY CITY ___ ______ ___ ___--___ ___ ______ ___ ___--___ ___ ______ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___  Cal MediConnect Plans:  Medi-Cal Plans:  Cal MediConnect Plans:  Medi-Cal Plans: IfIf you do NOT make a choice, you will be automatically enrolled in a Cal MediConnect Plan we have chosen for you. you do not make a choice, you will be automatically enrolled in a Cal MediConnect Plan we have chosen for you. City Zip Code Date of Birth Address, Address, City City Zip Zip Code Code Date Date of of Birth Birth IfAddress, you do not make a choice, you will be automatically enrolled in a Cal MediConnect Plan we have chosen for you. Address, Address,City City Zip ZipCode Code Date Dateof ofBirth Birth 304 800 L.A. 304 L.A. L.A. Care Care Health Health Plan Plan 800 L.A. Care Care OR OR --------OPTION B OPTION A OPTION OPTION A OR OPTION A OPTION BB___ Pla Part ers Pla Part ers ((((___ ___ ___ ___ ___ ___ ) ) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___   If If pregnant, pregnant, due due date date ______ ___ ___ ___ ___ ___ ___ ___ ___ ___ Sex: Sex:   Male Male   Female Female 801 Health Net ___ ______ ___ ___--___ ___ ______ ___ ___--___ ___ ______ ___ ___ Pla Part ers ___ ___ ___ ___ ___ ) ) ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___   If If pregnant, pregnant, due due date date ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Sex: Sex:  Male Male  Female Female 801 Health Net Combine benefits in Keep my Medicare the way it is now AND choose a Combine my Medicare and Medi-Cal Keep my Medicare the way it is now AND choose a (Area Code) Phone Number my Medicare and Month Day Year (Area (Area Code) Code) Phone Phone Number Number CF Care1st Partner Plan, LLC Month Month Day Day Year Year CF Care1st Partner Plan, LLC Combine my Medicare and Medi-Cal benefits in Keep my Medicare the way it is now AND choose a (Area (Area Code) Code) Phone Phone Number Number Month Day Day Year Year CF Care1st Partner Plan,Month LLC 816 Molina 816 Molina Dual Dual Options Options one plan. one Medi-Cal Medi-Cal plan. plan. one plan. plan. KA KP Cal, LLC Medi-Cal plan. KA KP Cal, LLC KA KP Cal, LLC 817 Care 1st PLEASE PLEASE READ READ the the Instructions and and Guidebook before completing completing this this form. form. 817one 1stCal PLEASE PLEASE READ the theInstructions Instructions Instructions andGuidebook Guidebook Guidebook before before completing completing this form. form. Choose Plans: Choose one these Medi-Cal Plans to Choosebefore one ofL.A. these Medi-Cal Plans toget getyour your Choose these MediConnect one of ofCare these CalREAD MediConnect LA Care Health Plan LAof L.A. Care Healththis Plan Choose one of these Cal MediConnect Plans: and Choose one of these Medi-Cal Plans to get your LA L.A. Care Health Plan 818 CareMore 818 CareMore Medi-Cal benefits: Medi-Cal benefits:   Cal MediConnect Plans:   Medi-Cal Plans: Plans: BC Anthem Medi-Cal benefits: BC Anthem Blue Blue Cross Cross Partnrshp Partnrshp  Cal Cal CalMediConnect MediConnect MediConnectPlans: Plans: Plans:  Medi-Cal Medi-Cal Medi-Cal Plans: Plans: BC Anthem Blue Cross Partnrshp 800 800 L.A. L.A. Care 304 304 L.A. Care Health Health Plan Plan 352 Health Net Comm Solutions 800 800 L.A. L.A.Care Care Care* 304 304 L.A. L.A. L.A.Care Care Care Health Health Plan Plan 352 Health Net Comm Solutions Pla Part ers Pla Plan Part Partners ers 801 Health Net 801 Health Net Pla Pla Part Part ers ers 801 Health Net Net 801 Health CF Partner Plan, LLC CF Care1st Care1st Partner Plan, LLC CF Care1st Partner Plan, LLC HN Health Comm Solutions HN Health Net Net Comm Solutions CF CF Care1st Care1st Partner Partner Plan, Plan, LLC LLC 816 Molina Dual Options 816 Molina Dual HN Health Net Comm Solutions 816 Molina Dual DualOptions Options 816 Molina Options KA Cal, KA KP Cal, LLC KA KP KP Cal,LLC LLC MO Molina Healthcare MO Molina Healthcare Partner Partner KA KA KP KP Cal, Cal, LLC LLC MO Molina Healthcare Partner 817 Care 1st 817 Care 817 Care1st 1st 817 Care 1st LA LA L.A. L.A. Care Care Health Health Plan Plan LA L.A. L.A.Care CareHealth HealthPlan Plan LA LA L.A. Care Health Plan 818 CareMore 818 CareMore 818 CareMore 818 CareMore BC BC Anthem Blue Cross Partnrshp BC Anthem AnthemBlue BlueCross CrossPartnrshp Partnrshp BC BC Anthem Anthem Blue Blue Cross Cross Partnrshp Partnrshp 352 352 352 352 Health Health Net Comm Solutions Health HealthNet Net NetComm Comm CommSolutions Solutions Solutions Pla ers Pla PlanPart Part Partners ers Pla Pla Part Part ers ers HN HN Health Health Net Comm Solutions HN Health HealthNet NetComm CommSolutions Solutions HN HN Health Net Net Comm Comm Solutions Solutions MO Molina Healthcare MO Molina Healthcare Partner MO Molina Healthcare Partner MO MO Molina MolinaHealthcare HealthcarePartner Partner Partner  Health doctor or code.  Health plan planplan doctoryou or clinic clinicbeen code. (See (See instructions) instructions) ** To To choose choose the the plan that that you have have been assigned assigned to, to, ** To To choose choose the the plan plan that you have been assigned to, select the plan with the asterisk (*). select theplan plan with___ the___ asterisk (*). ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___(*). ___ ___ ___ ___ ___ select the with the asterisk select the plan with ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ PACE the Care for the Elderly: PACE (Program of the All-Inclusive All-Inclusive Care for the Elderly:  If you are changing your health plan, enter your Program of the All-Inclusive Care for the Elderly (PACE): PACE (Program of the All-Inclusive Care for the Elderly: may If(Program you are of changing your health plan, enter your You qualify for PACE (see instructions). If you want Youmay may qualify forPACE PACE (seecode instructions). If you you want want to to get get You qualify for (see instructions). You may qualify for If to get plan change reason number. plan change reason code number. your Medicare and Medi-Cal benefits combined in a PACE yourMedicare Medicare and Medi-Cal benefits combined in a PACE your and Medi-Cal benefits combined plan, your Medicare and in a PACE (See instructions) (See instructions) plan, out this option in to Option A B. plan, fill out this option in addition addition tocode. Option A or orinstructions) B.   Health Health plan plan doctor or ortoclinic clinic code. (See instructions) fill outfill this option indoctor addition Option A or(See B. plan, fill out this option in addition to Option A or B. PACE Plan:  PACE Plan: PACE Plan: PACE Plan:  PACE Plan: 052 052 AltaMed AltaMed Senior Senior BuenaCare BuenaCare   Health Health plan plan doctor doctor or or clinic clinic code. code. (See (See instructions) instructions) you do not qualify, you will get your care through the you___ donot not qualify, you will get your care through the IfIfIfIfyou do you will get your you do not qualify, you will get your the ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___qualify, ___ ______ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___care ___ ___through ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Option A or Option B plan that you chose above in Step 2. Option A or Option B plan that you chose above in Step 2. Option B plan that you chose STOP! Read the important information on OptionAAor orOption Option B plan that you chose above in Step 2. STOP! Read the important information on the the back back before before you you sign sign this this form. form. II understand that by filling out and signing this form, II am choosing how to get my care.   PACE Plan: Plan:   you you are are changing changing your your health health plan, plan, enter enter your your understand that by filling out and signing this signing. form, am choosing how toby getfilling my health health care.signing this  PACE PACE PACE Plan: Plan:  IfIfIfIf3: you are are changing changing your your health health plan, plan, enter enter your your STEP Read the important information before signing. I understand that out and STEP 3: on back before Read the important information STEP 3:you Read the important information on the the back before signing. plan change reason reason code number. 052 052 AltaMed Senior BuenaCare form,plan I amchange choosing how code to getnumber. my health care. plan plan change change reason reason code code number. number. 052 052 AltaMed AltaMed AltaMedSenior Senior SeniorBuenaCare BuenaCare BuenaCare (See (See instructions) instructions) (See (See instructions) instructions) Beneficiary’s Beneficiary’s signature signature Beneficiary’s signature Beneficiary’s Beneficiary’s signature Beneficiary’s signature signature Beneficiary’s signature Date Date Date Date Date Date Date OR OR OR OR OR OR OR Authorized Representative Signature (if any) Date AuthorizedRepresentative RepresentativeSignature Signature(if (ifany) any) Date Date Authorized Representative Signature (if any) Date Authorized Authorized Representative Authorized Representative Signature Signature (if (if any) any) Date Date Authorized Representative Signature (if any) Date *CCIPA*STOP! STOP! Read the important information on on the back before you sign this form. STOP! STOP! Read Read Readthe the theimportant important importantinformation information information on onthe the theback back backbefore before beforeyou you yousign sign signthis this thisform. form. form. Highly Confidential CCIPA CCIPA CCIPA Highly Confidential Confidential Highly Highly Confidential MU_0004000_ENG1_0714 (070814) Confidential MU_0004000_ENG1_0714 IIIIunderstand understand that by filling out and signing this form, am choosing how to get my health care. understand understandthat that thatby by byfilling filling fillingout out outand and andsigning signing signingthis this thisform, form, form,IIIIam am amchoosing choosing choosinghow how howto to toget get getmy my myhealth health healthcare. care. care. MU_0004000_ENG1_0214 MU_0004000_ENG1_0214 MU_0004000_ENG1_0714 (070814) MU_0004000_ENG1_0714 (070814) MU_0004000_ENG1_0214