Choice Book -

TDD/TTY1-800-430-7077

u X - *140921FWDX041014* t

JOHN SAMPLE

1234 SAMPLE STREET

SAMPLE CITY, CA 99999

X-140921FWD-04/10/14

MU_0003507_ENG1_0311

121X131C-000002-37-7-M-M

To the addressee or guardian of:

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

121X131C-000002

1-844-580-7272

For TDD Users, call 1-800-430-7077

MU_0003507_ENG2_1204

121X131C-000002

u X - *140921FWDX041014* t X-140921FWD-04/10/14

1-844-580-7272

For TDD Users, call 1-800-430-7077

MA_IA_ENG_0311

April 10, 2014

To the addressee or guardian of:

u X - *140921FWDX041014* t

JOHN SAMPLE

1234 SAMPLE STREET

SAMPLE CITY CA 99999

X-140921FWD-04/10/14

State of California-Health and Human Services Agency

Department of Health Care Services

P.O. Box 989009

West Sacramento, CA 95798-9850

Welcome to Medi-Cal Managed Care!

We’re happy to welcome you and your family member(s) to Medi-Cal Managed Care.

We look forward to working with you to keep your entire family healthy. That’s our

number one concern.

The beneficiary(ies) listed on the enclosed choice form must choose a health plan

and doctor. You have until May 10, 2014 to complete and return the choice form.

You can make a plan choice at any time before the date listed above. The effective

date of your plan enrollment will depend on when we receive your plan choice. Your

plan choice could be effective as early as the first of the next month. After your plan

choice has been received and processed, you will receive a letter with your chosen

health plan’s name and start date. Your new health plan will also send you some

information once you are enrolled.

If you have any questions or want to enroll over the phone, call Health Care Options,

toll-free, at 1-844-580-7272, between the hours of 8:00 a.m. and 5:00 p.m., Monday

through Friday. If you need personal assistance, take a look at the presentation

schedule in the packet for site locations near your home or visit us on-line. Go to

www.healthcareoptions.dhcs.ca.gov. For TDD/TTY users, call 1-800-430-7077.

Take the first step toward providing yourself and your family with health care by

completing a choice form today! Get a good start on the road to health!

121X131C-000002-37-7--M

1-844-580-7272

1-844-580-7272

079 KP Cal, LLC

068 Health Net Comm Solutions

167 Care1st Partner Plan, LLC

131 Molina Healthcare Partner

029 Community Hlth Grp Partner

079 KP Cal, LLC





000 Regular Medi-Cal (FFS)

079 KP Cal, LLC






MU_0003451_ENG_0707

JOHN SAMPLE

1234 SAMPLE STREET SAMPLE CITY 99999

*M-0-95094517E-X*

*0000140921FWD-X*

2549158064

*M-0-95094517E-X*

*0000140921FWD-X*140921FWD-X

M- -95094517E-XJOHN SAMPLE

1-844-580-7272

079 KP Cal, LLC





079 KP Cal, LLC






079 KP Cal, LLC






MU_0003451_ENG_0707

JOHN SAMPLE

1234 SAMPLE STREET SAMPLE CITY 99999

*M-0-95094517E-X*

*0000140921FWD-X*

2549158064

*M-0-95094517E-X*

*0000140921FWD-X*140921FWD-X

M- -95094517E-XJOHN SAMPLE

1-844-580-7272

IMA

GE

MIS

SIN

G

You are receiving this form because you are eligible to enroll in a new Medi-Cal health plan. Your new plan will use this form to make sure you get needed care. Pleasefillinthecirclewithblackorbluepenfor the answers that apply to you. Complete one form for each person in your family who is enrolling in a new Medi-Cal health plan.

If you have questions, please call Health Care

Options, toll free at 1-800-430-4263 Monday through Friday, between 8:00 a.m. and 5:00 p.m. TDD/TTY users should dial 1-800-430-7077.

Please return completed form with your Medi-Cal Choice Form or mail separately to:CA Department of Health Care Services Health Care Options - PO Box 989009 West Sacramento, CA 95798-9850

Health Information Form

MU_0003754_ENG_0912CONFIDENTIAL

I understand that this information will be disclosed to Health Care Options and my new plan.

Signature: Date Signed:

When you become a health plan member, DHCS will send this information to your Medi-Cal health plan.

If you think you need to see a doctor before your Medi-Cal health plan contacts you, you should go to the doctor or hospital at that time.

Filling out this form is voluntary. You will not be denied care based on your confidential answers.

1. Do you need to see a doctor within the next 60 days? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

2. Do you take 3 or more prescription medicines each day? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

3. Do you see a doctor regularly for a mental health condition suchas depression, bipolar disorder, or schizophrenia? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

4. Have you been to the emergency room two or more times in thelast 12 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

5. Have you been admitted to the hospital in the last 12 months? . . . . . . . . . . . . . . . . . . . . Yes No

6. Have you needed help with personal care, such as bathing, gettingdressed, or changing bandages in the last 6 months? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

7. Are you using medical equipment or supplies, such as a hospital bed,wheelchair, walker, oxygen, or ostomy bags? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No

8. Do you have a condition that limits your activities or what you can do? . . . . . . . . . . . . . . . . . Yes No

9. Are you pregnant? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No9a. If Yes, are you currently seeing a doctor for this pregnancy? . . . . . . . . . . . . . . . . . . . . . . Yes No

10. Do you see a doctor regularly for a chronic medical condition? . . . . . . . . . . . . . . . . . . . . . . . Yes No If Yes, fill in all that apply:

Born In: Name of Person Completing Form:

Asthma Cancer Cystic Fibrosis DiabetesHeart Problems Hepatitis High Blood Pressure HIV or AIDSKidney Disease Seizures Sickle Cell Anemia TuberculosisOther

Ifnotsignedbybeneficiary,specifyrelationship:Parent of minor Guardian Other representative

*1010*1010

JOHN SAMPLE 2007 *140921FWD-0003761319**140921FWD-0003761319*140921FWD - 0003761319

1-844-580-7272

MU_0003519_ENG1_0707A

1-844-580-7272

1-844-580-7272

MU_0003519_ENG3_0707A

1-844-580-7272

1-844-580-7272

1-844-580-7272

1OZ_

0003

491_

EN

G1_

0211

a

Do not put m

ore than 4 forms in this envelope

1OZ_0003491_E

NG

2_1012

1-844-580-7272

1-844-580-7272

SD_0003327_ENG2_0312

Care 1st Partner Plan Community Health Group Partnership Plan (Community Health Group)

StandardBenefits

Medi-Cal Covered Services Medi-Cal Covered Services

PlanNetworkHospitals*

*In the event of anemergency, call 911

Fallbrook HospitalParadise Valley HospitalPalomar Medical CenterPomerado HospitalRady Children’s Hospital San DiegoScripps Green HospitalScripps Memorial Hospital-EncinitasScripps Memorial Hospital-La JollaScripps Mercy HospitalScripps Hospital-Chula VistaSharp Chula Vista Medical CenterSharp Coronado HospitalSharp Gossmont HospitalSharp Memorial HospitalSharp Mary Birch Hospital for Womenand Tri City Medical Center

Alvarado HospitalFallbrook Hospital Green Hospital of Scripps ClinicGrossmont HospitalPalomar Medical Center Paradise Valley Hospital Pomerado Hospital Promise Hospital of San DiegoRady Children’s Hospital of San DiegoScripps Memorial Hospital EncinitasScripps Memorial Hospital La JollaScripps Mercy Hospital Chula VistaScripps Mercy Hospital HillcrestSharp Chula Vista Medical CenterSharp Coronado Hospital Sharp Mary Birch Hospital for WomenSharp Memorial HospitalTri-City Medical Center

Doctors you can go to Please call Member Services at 1-800-605-2556 for a directory or assistance in choosing a doctor, or you can go online to www.care1st.com for all networkinformation.

We have over 500 Primary Care Physicisans who work directly with over 1,200 Specialists. Please look in Community Health Group’s Provider Directory for a doctor near your home.

Urgent Care Centers Call your provider during business hours.After hours, call 1-800-605-2556.

Community Health Group offers after-hours access to urgent care.

Pharmacies The Care1st Health Plan pharmacy network includes most of the large chains such as CVS, Rite Aid and Walgreens along with many neighborhood pharmacies.

Our network includes 400 pharmacies, many chain and independent pharmacies. Please look in Community Health Group’s Provider Directory for a pharmacy near your home.

Vision Plan Care1st Health Plan offers access to vision services through March Vision.

Vision Service Plan for your vision benefits. If you are 21 years of age or older, some limitations may apply.

Assistance with Public Transportation

Free transportation to your doctor’s appointments. Some restrictions may apply. Call 1-877-433-2178 from 8:00 am to 6:00 pm, Monday - Friday.

24-hour emergency transportation services.For non-emergent transportation, contact Community Health Group.

Health Education

Care1st Health Plan offers Asthma Management, Healthy Start (Comprehensive Prenatal and Post Partum), Quitting Smoking and Weight Management programs.

• Health Education Classes and Community Events inyour area;• Member Newsletters

Languages Spanish, Russian, Mandarin, Vietnamese, Armenian, Hmong, Cantonese. Other languages available through the language line services.Call Member Services: 1-800-605-2556

Our Member Services staff speaks English, Spanish, Vietnamese and Arabic and many more through the use of the Language Line.

Member Services Hotline

1-800-605-2556 Member Servcie Department 1-800-224-7766. TTY 1-800-735-2929; 24 hours a day, 7 days a week.Telephone Advice Nurse 1-800-647-6966.

Medi-Cal Managed Care Comparison ChartThe information is being provided for INFORMATION purposes only. To order an enrollment package, or for

assistance filling one out, call 1-844-580-7272. Translators are available. For TDD/TTY users, call 1-800-430-7077.

SD_0003327_ENG3_0312

Health Net Community Solutions, Inc.(Health Net)

KP Cal, LLC(Kaiser Permanente)

Molina Healthcare of California PartnerPlan, Inc. (Molina)

Medi-Cal Covered Services Medi-Cal Covered Services Medi-Cal Covered Services. Bridge2AccessSM Program-to help members access care.

Alvarado Hospital Medical CenterRady Children’s HospitalScripps Green HospitalScripps Memorial Hospital - EncinitasScripps Memorial Hospital - La JollaScripps Mercy HospitalScripps Mercy Hospital - Chula VistaTri-City Medical CenterUCSD Medical Center - HillcrestUCSD Medical Center - ThortonCovers emergency services anywhere.

Kaiser Permanente HospitalsHospital and Medical Offices: 4647 Zion Ave.

Fallbrook HospitalRady Children’s Hospital San DiegoScripps-Mercy HospitalScripps-Mercy Hospital-Chula VistaSharp-Chula Vista Medical Center Sharp-Coronado HospitalSharp-Grossmont HospitalSharp-Mary Birch Hospital for WomenSharp Memorial HospitalTri-City Medical Center

Our provider directory can help you choose from several participating primary care providers and specialists or call Member Services at 1-800-675-6110.

Per Kaiser Permanente Provider Directory/EOC Primary Care Physician (PCP) Assignment and PCP Re-selection through Member Services 1-800-464-4000.

Over 1,900 Primary Care Physicians and Specialists. Call 1-888-665-4621 for a directory or assistance in finding a doctor.

Call Member Services Department 24 hours/7 days for assistance.

Urgent Care is offered at most sites:Through most clinics (as identified in the Provider Directory) Through Medical Services ERs/EDs.

24-hour statewide emergency services at over 70 locations, as well as 24-hour Nurse Advice Line at 1-888-275-8750.

Choose from a large selection of chain and independent pharmacies including CVS, K-Mart, Rite Aid, Target, Vons, Walgreens,Wal-Mart, and many others.

Pharmacies at every Kaiser location: San Diego, Bonita, Carlsbad, Clairmont, Eastlake, El Cajon, Escondido, La Mesa, Mission Bay, Otay Mesa, Point Loma, Rancho Bernardo, San Marcos and Vista. Call 1-800-464-4000.

6,000 pharmacies state-wide, including convenient neighborhood pharmacies like CVS, Rite Aid, and Walgreens.

Our provider directory can help you find an eye care professional. Call us at 1-800-675-6110.

Vision Services are available at all clinic locations. Phone numbers, appointments, and addresses are published in the Provider Directory.

Members have access to March Vision’s Provider Network, with many vision care service locations.

24-Hour Emergency Transportation is available. Call Health Net Member Services at 1-800-675-6110 if you need assistance with non-emergency transportation.

Directions, phone numbers and maps to all sites are in the Provider Directory. Directions are also available at 1-800-464-4000.

When medically necessary, Molina offers 24-hour emergency and pre-arranged non-emergency transportation.

Materials on many health topics. Programs in weight management, nutrition, smoking cessa-tion, asthma, diabetes and more. Call 1-800-804-6074 for more information.

Health Education Centers are available at all clinic sites. Call Member Services at 1-800-464-4000 for the telephone numbers.

Programs and materials available including: stop smoking, weight control, chronic diseases like diabetes and asthma, and Motherhood Matters Pregnancy Program.

Our representatives speak Spanish, Hmong, and other languages. TDD/TTY: 1-800-431-0964. Call 1-800-675-6110 for assistance.

Most languages are supported by clinic sites through Kaiser staff, contracted interpreter services or AT&T interpreter services (on-line).

Multi-lingual staff available. We offer interpreters (including Sign Language) to meet you at doctor visits and telephone interpreter services in over 160 languages.

Call our Member Services Department 24/7 at 1-800-675-6110. Call 1-800-327-0502 for answers about Medi-Cal Managed Care.

Provided for all sites. Listed in the Provider Directory by location, hours and phone number.

1-888-665-4621 (M-F, 7am – 7pm). Deaf and hard of hearing members TDD/TTY 1-800-479-3310 or dial 711 (Calif. Relay Services).

Medi-Cal Managed Care Comparison ChartThe information is being provided for INFORMATION purposes only. To order an enrollment package, or for

assistance filling one out, call 1-844-580-7272. Translators are available. For TDD/TTY users, call 1-800-430-7077.

1-844-580-7272

1-844-580-7272

1-844-580-7272

Getting needed careChildren got the care they needed without problems.

Getting care quicklyChildren got appointments and treatment without long waits.

How well doctors communicateDoctors listened carefully, gave good explanations, and showed respect.

Shared decision makingDoctors talked with parents about treatment choices for the child and asked which was best for the child.

Plan customer serviceParents got the help they needed from plan customer service and plan written materials.Vaccines (shots) for childrenChildren got all of the vaccines (shots) they were supposed to have to prevent illness.

Check-ups for teenagersTeenagers got all of the check-ups they were supposed to have.

Care for children with colds and fluChildren with colds and flu got the right kinds of treatment.

Care1st

Partner Plan,

LLC

Community

Hlth Grp

Partner

KaiserHealth Net

Comm

Solutions

Molina

Healthcare

Partner

MU_0003642_ENG2_0412

Adults

5 For more information about Medi-Cal health plans call 1-800-430-4263

Getting needed carePeople got the care they needed without problems.

Getting care quicklyPeople got appointments and treatment without long waits.

How well doctors communicateDoctors listened carefully, gave good explanations, and showed respect.

Shared decision makingDoctors talked with patient about treatment choice and asked which was best for the patient.

Plan customer servicePeople got the help they needed from plan customer service and plan written materials.

Pregnancy carePregnant women got regular check-ups before their baby was born.

Testing diabetics’ blood sugar levelAdult diabetics (type 1 and 2) tested for the amount of sugar in their blood.

Care for adults with bronchitisAdults with bronchitis got the right kinds of treatment.

= Scored lower than the average for Medi-Cal plans in California.

= Scored higher than the average for Medi-Cal plans in California.

= Scored about the same as the average for Medi-Cal plans in California.

This is what the symbols mean:

= Too few Medi-Cal plan members to report OR results were not available.

1-844-580-7272

Care1st

Partner Plan,

LLC

Community

Hlth Grp

Partner

KaiserHealth Net

Comm

Solutions

Molina

Healthcare

Partner

Questions about Medi-Cal

Look in your enrollment booklet, calledMy Medi-Cal Choice for Healthy Care.

Call 1-800-430-4263 to talk to someone at Health Care Options. It’s a free call.

The TDD/TTY number is 1-800-430-7077. This phone number is for people who have difficulties with hearing or speech. You need special equipment to use it.

Medi-Cal holds meetings all over the state tohelp people understand the Medi-Cal programand how to sign up. You can come to one of these meetings if you want to hear about your choices and ask questions in person. To findout where and when meetings are held, lookin the booklet My Medi-Cal Choice for Healthy Care or call Health Care Options at

1-800-430-4263.

How to file a grievance

If you have trouble getting an interpreter when you need one, or getting important written materials translated, you have the right to file a grievance. To file a grievance you may call your health plan or send them a letter.

At the same time that you file a grievance with your health plan, you can ask for a State Hearing. Call 1-800-952-5253 (TDD/TTY: 1-800-952-8349) to ask for a State Hearing or send a letter to:

California Department of Social ServicesState Hearing DivisionP.O. Box 944243, MS 9-17-37Sacramento, CA 94244-2430

Questions about the health plans

If you have questions about how to use the plans and the programs or services they offer, you can call these phone numbers:

Funding for the development of this guide was provided by the California HealthCare Foundation.

MU_0003637_ENG_1011

sss

Where to get answers ifyou have questions

Care1st Partner Plan, LLC

1-866-852-2731

TDD/TTY: 1-888-757-6034

Community Hlth Grp Partner

1-800-224-7766

TDD/TTY: 1-800-735-2929

Health Net Comm Solutions

1-800-675-6110

TDD/TTY: 1-800-735-2929

Kaiser

1-800-464-4000

TDD/TTY: 1-800-777-1370

Molina Healthcare Partner

1-888-665-4621

TDD/TTY: 1-800-479-3310

1-844-580-7272

1-844-580-7272

1-844-580-7272

1-844-580-7272

Health Care OptionsPresentations

Page 1 of 2

MSM-C-M61 SD_LTSS_PRES_ENG1_0614

CITY LOCATION ZIP CODE

Chula Vista South Bay 690 Oxford Street

91911

El Cajon El Cajon 220 South First Street

92019

Escondido Escondido 620 East Valley Parkway

92025

Lemon Grove

Lemon Grove 7065 Broadway

91945

Oceanside Oceanside 1315 Union Plaza Court

92054

Attend an informative session at one of these convenient locations.

California Health Care Options (HCO) Presentation SitesSan Diego County

June 2014 Schedule

In-Person Medi-Cal Managed Care Information Just ask for the "Health Care Options"

Representative Appointment Necessary Free Help To Complete Forms

ENROLLMENT COUNSELOR

619-409-3296

619-401-6184

760-740-4069

619-668-3784

760-754-5860

You can call the HEALTHY SAN DIEGO Information Line at 1-844-580-7272. Please leave a message with your name and telephone number and someone will return your call within 24 hours.

Health Care OptionsPresentations

Page 2 of 2

MSM-C-M61 SD_LTSS_PRES_ENG2_0614

CITY LOCATION ZIP CODE

Centre City 1255 Imperial Avenue

92101

Kearny Mesa 5055 Ruffin Road

92123

Northeast 7290 El Cajon Boulevard

92115

Southeast 4588 Market Street

92101

Attend an informative session at one of these convenient locations.

California Health Care Options (HCO) Presentation SitesSan Diego County

June 2014 Schedule

In-Person Medi-Cal Managed Care Information Just ask for the "Health Care Options"

Representative Appointment Necessary Free Help To Complete Forms

ENROLLMENT COUNSELOR

619-237-8506

858-573-7341

619-337-6240

619-266-3963

You can call the HEALTHY SAN DIEGO Information Line at 1-844-580-7272. Please leave a message with your name and telephone number and someone will return your call within 24 hours.

San Diego

1-844-580-7272

1-844-580-7272

Report The Problem To The California Department Of Managed Health Care’s Office Of Patient Advocacy

• Call 1-888-466-2219, 24 hours a day, seven days a week.

Ask For A State Fair Hearing With An Administrative Law Judge

• If you want a State Fair Hearing, you must ask for it within 90 days from the date ofthe “Notice of Action” or “Grievance Resolution” letter that you receive from yourhealth plan, or from the date of the order or action you are complaining of.

• If the “Notice of Action” letter states that your requested treatment is terminated orreduced and you want to keep your treatment going, you must ask for a State FairHearing within 10 days from the date the letter was postmarked or personally deliveredto you, or before the effective date of the action you’re disputing, whichever is earlier.

• Complete the “Form To File A State Fair Hearing” that is included with your “Noticeof Action” letter.

• You can also send a personal letter to ask for a State Fair Hearing. Be sure to includeyour name, address, phone number, Social Security Number, and the reason you wanta State Fair Hearing. If someone is helping you ask for a State Fair Hearing, addhis/her name, address, and phone number to the letter.

• If you want to keep your treatment going during the hearing process, be sure to statethat in the “Form To File A State Fair Hearing” or in your personal letter.

• If you need a free interpreter, state that in the “Form To File A State Fair Hearing”or inyour personal letter. Include the language that you speak.

• It takes up to 90 days after you ask for a hearing to get an answer. If you think waitingthat long will threaten your health, ask your doctor or health plan for a letter. Makesure the letter explains how waiting will threaten your health. Then, ask for anexpedited hearing and include the letter with the “Form To File A State Fair Hearing”or with your own personal letter.

State Fair HearingWrite to:

California Department of Social Services State Fair Hearing DivisionPO Box 944243, MS 9-17-37Sacramento, CA 94244-2430

Call: 1-800-952-5253 TDD/TTY:1-800-952-8349

MV_0003522_ENG2_1011

How To Get An Exemption/Waiver

You or a member of your family must choose a health plan if:

• You receive CalWorks benefits (cash aid, food stamps)• You receive Medi-Cal only and you do not have a share of cost

You or a member of your family cannot choose a health plan if:

• You are a member of a commercial health plan through private insurance• You receive share of cost Medi-Cal

You or a member of your family may not have to choose a health plan if:

• You receive health services from an Indian Health Provider• You are being treated for a complex medical condition, such as:

• Pregnancy• Cancer• Organ transplant (or are scheduled for one)• Renal disease and have dialysis at least two times a week• A disease that affects more than one organ system (such as diabetes)• You are HIV positive• Other conditions may qualify

How To Get An Exemption/Waiver

• You and your doctor must complete and sign the Medical or Non-MedicalExemption Form in this packet. Your doctor may not authorize your medicalexemption, if he or she is part of a Medi-Cal Managed Care Health Plan inyour area.

• You must return the form no later than 30 days after you receive this packet.• If you do not return the form within 30 days, the State will choose a health

plan for you.• The State will review your request to change you to Regular Medi-Cal

(Fee-For-Service).• The State will send you a letter to let you know if your request has been

approved or denied.• If denied, you can call the State’s Ombudsman at 1-888-452-8609. The

call is free.

MA_0003537_ENG_0712

MU_0003383_ENG1_0413

*1**SEPARATOR*

1-844-580-7272

1-844-580-7272.

1-844-580-7272

LT_0003382_ENG_0314

State of California - Health and Human Services Agency Department of Health Care Services

Medi-Cal Managed CareNon-Medical Exemption

Excepción Por Razones No Médicas Para Atención Médica Administrada de Medi-Cal

Request for Non-Medical Exemption from Plan EnrollmentAmerican Indians and Beneficiaries with HIV/AIDS

Each area of this non-medical exemption form must be completed or the form will be returned unprocessed.

Please Print or Type (Ink Only)Dear Service Facility or Provider: If you currently provide or will be providing medical services to an individual who is receiving

Medi-Cal benefits and that individual is required to enroll in a health plan, completion of this form will enable the individual to receive services through your facility as an alternative to enrollment in a Medi-Cal Managed Care health plan. The exemption form is valid until the individual chooses to enroll in a Medi-Cal Managed Care health plan.

1. Beneficiary Name

Last Name First Name M.I.

2. Beneficiary Medi-Cal I.D. Number (BIC)

___ ___ ___ ___ ___ ___ ___ ___ ___ ___

3. Name of Service Facility or Provider

I certify that the information I have provided on this form is correct. I understand that the Department of Health Care Services may audit this form to determine if the information provided is accurate.

4a. Authorized signature of Medi-Cal Provider 4b. Date signed__ __ __ __ __ __Month Day Year

4c. Printed name of Medi-Cal Provider

Last Name First Name M.I.

4d. NPI used to bill the Medi-Cal Program for this beneficiary.

___ ___ ___ ___ ___ ___ ___ ___ ___

5. Telephone number of Medical Provider

(___ ___ ___) ___ ___ ___— ___ ___ ___ ___

6. Fax number of Medical Provider

(___ ___ ___) ___ ___ ___— ___ ___ ___ ___

9. Telephone number of Medical Physician

(___ ___ ___) ___ ___ ___— ___ ___ ___ ___

10. Fax number of Medical Physician

(___ ___ ___) ___ ___ ___— ___ ___ ___ ___

Dear Medi-Cal Beneficiary: If you or a family member is receiving Medi-Cal benefits, you may be required to join a Medi-Cal Managed Care health plan. However, if you or a family member is a qualified individual for this exemption and you want to receive medical services through your choice of facility or provider, you may request to be excused from Medi-Cal Managed Care health plan enrollment in order to receive services through a service facility or provider of your choice.

To be excused from plan enrollment you must have a service facility representative complete this form, certifying that you are or will be receiving services from a service facility or provider of your choice. The facility representative must submit this completed form to Health Care Options.

Estimado beneficiario de Medi-Cal: Si usted o un miembro de su familia está recibiendo beneficios de Medi-Cal, es posible que deba inscribirse en un Plan de Salud Administrado de Medi-Cal. Sin embargo, si usted o un miembro du su familia es de origen IndígenaAmericano, Nativo de Alaska o reúne los requisitos para personas deorigen no indígena y desea recibir servicios medícos a través de uncentro de Indian Health Service (IHS), puede solicitar que esté excluidode inscribirse en un plan de salud de Atención Médica Administrada de Medi-Cal para recibir los servicios a través del centro de Indian Health Service.

Para que esté excluido de inscribirse en el plan, debe solicitarle a un representante del centro de Indian Health Services que llene este formulario, en el que certifica que usted recibe o recibirá servicios a través de un centro de Indian Health Service. El representante del centro debe enviar este formulario completo al programa HCO.

Mail completed form to:Health Care OptionsP.O. Box 989009West Sacramento, CA 95798-9850

or Fax this form to: (916) 364-0287If you have any questions regarding this form, please call HCO at 1-844-580-7272; TTY/TDD users, call 1-800-430-7077

Spanish Translation Here

1-844-580-7272

1-844-580-7272

Date post:	11-Sep-2021
Category:	Documents
Upload:	others
View:	12 times
Download:	0 times

Choice Book -

Documents