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The Medical Choice Form is a vital document for individuals and families enrolled in Medi-Cal, California's Medicaid program. It allows beneficiaries to select their preferred health plan and manage their healthcare needs effectively. The form requires clear and accurate information about each household member receiving Medi-Cal benefits, including personal details such as names, social security numbers, and contact information. Applicants must indicate their health plan choice from options like Blue Cross, HealthNet, Kaiser, and others, while also providing necessary clinic or doctor codes. For those with more than three family members, additional forms can be requested. Importantly, the form includes a statement of understanding, ensuring that applicants are aware of how their information will be used and the implications of their health plan choices. For assistance, individuals can reach out to a dedicated helpline, ensuring that help is readily available for those who need it. Completing the Medical Choice Form accurately is essential for seamless enrollment and access to necessary healthcare services.

Medical Choice Example

Medi-Cal Choice Form Please fill in both sides.

For free help filling out this form, call 1-800-430-4263.

1. Please print. Use a blue or black pen.

 

 

3. Fill in all information for each person in your household who gets Medi-Cal.

2. Fill in the

to show your choice. Fill it in completely:

 

4. If you have more than 3 family members, call 1-800-430-4263 to ask for another form.

 

 

 

 

 

 

 

 

 

 

Head of Household

 

 

 

 

 

 

Sex:

Male

Female

__________________________________

________________________________________

( ___ ___ ___ ) ___ ___ ___ – ___ ___ ___ ___

Ç First Name

 

 

Ç Last Name

 

 

 

 

Ç Area Code

 

Ç Telephone or Cell Phone Number

__________________________________________________________

____________________________________ ___ ___ ___ ___ ___

Ç Home Address: house number, street name, apartment number

 

 

Ç City

 

 

 

Ç Zip Code

 

 

 

 

 

 

 

 

 

 

 

1st Applicant

 

 

 

 

 

 

 

 

 

 

__________________________________

________________________________________

Sex:

Male

Female

Ç First Name

 

 

Ç Last Name

 

 

 

 

 

 

 

___ ___ ___

– ___ ___ –

___ ___ ___ ___

If pregnant, due date: ___ ___

– ___ ___

– ___ ___

 

Ç Social Security Number

 

 

 

 

Ç Month

Ç Day

Ç Year

 

 

I want to be in:

Blue Cross*

Care 1st*

HealthNet*

Kaiser*

Western Health Advantage*

Regular Medi-Cal (No clinic code needed)

*Doctor or clinic code for your new health plan choice above: ___________________________________

 

 

 

(To find the code number, look in the Provider Directory for the plan you choose. It is usually written under the name of your provider. It can also be called a “PCP#” or “Provider Identification Number.”)

2nd Applicant

 

 

 

 

 

 

 

 

__________________________________

________________________________________

Sex: Male

Female

Ç First Name

 

 

Ç Last Name

 

 

 

 

 

___ ___ ___

– ___ ___ –

___ ___ ___ ___

If pregnant, due date: ___ ___

– ___ ___

– ___ ___

 

Ç Social Security Number

 

 

 

Ç Month

Ç Day

Ç Year

 

I want to be in:

Blue Cross*

Care 1st*

HealthNet*

Kaiser*

Western Health Advantage*

Regular Medi-Cal (No clinic code needed)

*Doctor or clinic code for your new health plan choice above: ___________________________________

 

 

(To find the code number, look in the Provider Directory for the plan you choose. It is usually written under the name of your provider. It can also be called a “PCP#” or “Provider Identification Number.”)

3rd Applicant

 

 

 

 

 

 

 

 

 

__________________________________

________________________________________

Sex: Male

Female

Ç First Name

 

 

Ç Last Name

 

 

 

 

 

 

___ ___ ___

– ___ ___ –

___ ___ ___ ___

If pregnant, due date: ___ ___

– ___ ___

– ___ ___

 

Ç Social Security Number

 

 

 

 

Ç Month

Ç Day

Ç Year

 

I want to be in:

Blue Cross*

Care 1st*

HealthNet*

Kaiser*

Western Health Advantage*

Regular Medi-Cal (No clinic code needed)

*Doctor or clinic code for your new health plan choice above: ___________________________________

(To find the code number, look in the Provider Directory for the plan you choose. It is usually written under the name of your provider. It can also be called a “PCP#” or “Provider Identification Number.”)

If anyone in your family is changing Medi-Cal Health Plans, please fill in all of the reasons why:

Please fill in

Could not choose desired doctor.

Plan did not meet needs.

Doctor did not meet needs.

Doctor was too far away.

other side.

Did not choose this plan.

Moving out of the county.

 

 

Other: ______________________________________________________________

Medi-Cal Choice Form Please fill in both sides.

For free help filling out this form, call 1-800-430-4263.

STATEMENT OF UNDERSTANDING: I understand that by filling out and signing this form, I am choosing how to get my Medi-Cal health care.

I understand that the Department of Health Care Services will keep the information on this form. They will only use it to enroll or disenroll me from a Medi-Cal Health Plan. Other government agencies that serve Medi-Cal members can also see this information. I can look at the files that Medi-Cal keeps on me, unless they are being used in an investigation or lawsuit. (To see your Medi-Cal file, contact the Department of Health Care Services at the address below.)

If You Chose a Medi-Cal Health Plan: I have read the description of the plan I want to join.

If You Join Kaiser: I understand that Kaiser requires binding arbitration. This means that I give up my right to a jury or court trial for medical malpractice and other disagreements about benefits 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.

Please Sign Below:

 

 

 

Head of Household

__________________________________________

Date: ___ ___ – ___ ___

– ___ ___

 

Ç Signature

Ç Month Ç Day

Ç Year

1st Applicant

 

if under 18 years, parent or guardian: __________________________________________

Date:

ÇSignature

2nd Applicant

 

if under 18 years, parent or guardian: __________________________________________

Date:

ÇSignature

3rd Applicant

 

if under 18 years, parent or guardian: __________________________________________

Date:

ÇSignature

___ ___ – ___ ___

– ___ ___

Ç Month

Ç Day

Ç Year

___ ___ – ___ ___

– ___ ___

Ç Month

Ç Day

Ç Year

___ ___ – ___ ___

– ___ ___

Ç Month

Ç Day

Ç Year

Mail To:

California Dept. of Health Services

 

Health Care Options

 

Box 989009

 

Please fill in

West Sacramento, CA 95798-9850

other side.

________________________________________________________________________________________________________________
Click for Medical Choice File

File Breakdown

Fact Name Description
Form Purpose The Medi-Cal Choice Form is used by individuals to select their Medi-Cal health care plan.
Eligibility This form must be completed for each person in a household who receives Medi-Cal benefits.
Contact Information For assistance in filling out the form, individuals can call 1-800-430-4263.
Submission Requirements All information on the form must be printed clearly using a blue or black pen.
Family Size If there are more than three family members, a second form must be requested by calling the provided number.
Health Plan Options Applicants can choose from several health plans, including Blue Cross, HealthNet, and Kaiser.
Statement of Understanding By signing the form, individuals acknowledge their understanding of the enrollment process and their rights regarding their health information.
Binding Arbitration If joining Kaiser, individuals agree to binding arbitration, waiving their right to a jury trial for certain disputes.
Mailing Address The completed form must be mailed to the California Department of Health Services at the specified address in West Sacramento.

Guide to Using Medical Choice

Filling out the Medical Choice form is an essential step in managing your Medi-Cal health care options. Follow these steps carefully to ensure that all required information is accurately provided. If you have any questions or need assistance, you can call 1-800-430-4263 for free help.

  1. Use a blue or black pen to print clearly.
  2. Complete both sides of the form.
  3. Provide all necessary information for each person in your household who receives Medi-Cal.
  4. Fill in your choice of health plan completely, including the doctor or clinic code if applicable.
  5. If you have more than three family members, call 1-800-430-4263 to request an additional form.
  6. For each applicant, include their first name, last name, sex, social security number, and if pregnant, the due date.
  7. Sign and date the form where indicated. If any applicants are under 18, a parent or guardian must sign on their behalf.
  8. Mail the completed form to the California Department of Health Services at the address provided on the form.

Get Answers on Medical Choice

What is the Medical Choice form?

The Medical Choice form is a document that allows individuals and families to select their Medi-Cal health plan. This form must be completed for each person in your household who is receiving Medi-Cal benefits. By filling out this form, you indicate your preferred health care provider and plan, ensuring you receive the medical care that best suits your needs.

How do I fill out the Medical Choice form?

To fill out the Medical Choice form, follow these steps:

  1. Use a blue or black pen to print clearly.
  2. Complete all sections for each household member receiving Medi-Cal.
  3. Indicate your choice of health plan by filling in the appropriate section.
  4. If your household has more than three members, call 1-800-430-4263 to request additional forms.

Make sure to double-check your information for accuracy before submitting the form.

What if I need help completing the form?

If you need assistance while filling out the Medical Choice form, you can call 1-800-430-4263. Trained representatives are available to guide you through the process and answer any questions you may have.

What information is required on the form?

The form requires the following information for each applicant:

  • Full name
  • Sex
  • Social Security Number
  • Home address
  • Telephone or cell phone number
  • Health plan choice
  • If pregnant, the due date

Ensure that all information is filled out completely and accurately.

What should I do if my family is changing Medi-Cal health plans?

If anyone in your family is changing their Medi-Cal health plan, you will need to provide reasons for the change on the form. Common reasons include:

  • Could not choose desired doctor
  • Plan did not meet needs
  • Doctor did not meet needs
  • Doctor was too far away
  • Moving out of the county
  • Other specific reasons

Make sure to clearly explain your reasons to help facilitate the change.

What happens after I submit the Medical Choice form?

Once you submit the Medical Choice form, the Department of Health Care Services will process your information. They will use it to enroll or disenroll you from your chosen Medi-Cal health plan. Your information will be kept confidential, but other government agencies that serve Medi-Cal members may access it.

What is the Statement of Understanding?

The Statement of Understanding is a section of the form where you acknowledge that you understand the implications of your choices. By signing this statement, you confirm that you are aware of how your information will be used and that you have read the descriptions of the plans available to you.

What if I choose Kaiser as my health plan?

If you select Kaiser, it is important to note that they require binding arbitration for disputes regarding medical malpractice and other disagreements about benefits and services. This means you will not have the option of a jury or court trial. However, you still have the right to request a Medi-Cal State Hearing if needed.

Where do I send the completed form?

After completing the Medical Choice form, mail it to:

California Dept. of Health Services
Health Care Options
Box 989009
West Sacramento, CA 95798-9850

Make sure to send it to the correct address to avoid any delays in processing your application.

Common mistakes

Filling out the Medical Choice form can be straightforward, but many people make common mistakes that can delay their enrollment or cause confusion. One major error is not printing clearly. The instructions specify that you should use a blue or black pen and print legibly. If the information is hard to read, it may lead to processing issues. Always take your time to ensure that your handwriting is clear and that you follow the instructions closely.

Another frequent mistake involves leaving out required information. Each section of the form asks for specific details about all household members receiving Medi-Cal. If you skip any fields, such as the Social Security number or the health plan choice, it could result in delays. Make sure to double-check that every box is filled out completely before submitting the form.

People often forget to indicate their health plan choice. This is a crucial part of the form. If you do not select a plan, the Department of Health Care Services cannot process your application. Make sure to fill in the plan you want and include the doctor or clinic code if applicable. If you're unsure about the code, refer to the Provider Directory as instructed.

Some applicants also overlook the need to sign the form. A signature is essential to validate your choices and confirm your understanding of the terms. Without it, the form is incomplete. Remember, if you are signing on behalf of a minor, a parent or guardian's signature is required for each applicant under 18.

Lastly, many people fail to mail the form to the correct address. The form must be sent to the California Department of Health Services at the specified address. Ensure that you have the correct mailing information and consider using a method that allows you to track the delivery. Taking these steps can help ensure that your application is processed smoothly and without unnecessary delays.

Documents used along the form

When navigating the Medi-Cal system, you may encounter various forms and documents that work in tandem with the Medical Choice form. Understanding these documents can help ensure that you receive the care and benefits you need. Below is a list of common forms that you may need to complete or refer to as part of your Medi-Cal journey.

  • Medi-Cal Application Form: This is the primary document used to apply for Medi-Cal benefits. It collects essential information about your household, income, and health needs to determine eligibility.
  • Notice of Action: This document informs you of decisions made regarding your Medi-Cal application or benefits. It explains whether your application was approved or denied and provides details about your rights to appeal.
  • Change Report Form: If your circumstances change—such as income, household size, or address—you need to fill out this form. It helps keep your Medi-Cal information current and accurate.
  • Medically Necessary Services Form: This form is used to request specific medical services that are deemed necessary for your health. It may require your healthcare provider's input to justify the need for those services.
  • Provider Directory: While not a form, this document lists all participating healthcare providers within Medi-Cal. It helps you find doctors, specialists, and clinics that accept Medi-Cal patients.
  • Health Plan Enrollment Form: If you choose to enroll in a specific Medi-Cal health plan, this form is required. It captures your selection and authorizes your enrollment in the chosen plan.
  • Authorization for Release of Information: This form allows Medi-Cal to share your health information with other healthcare providers or entities, ensuring continuity of care.
  • Appeal Form: If you disagree with a decision made by Medi-Cal regarding your benefits or services, this form enables you to formally appeal that decision.
  • Emergency Medi-Cal Application: In urgent situations, this form allows individuals to apply for Medi-Cal benefits quickly, ensuring they receive necessary medical care without delay.
  • Annual Renewal Form: Once you are enrolled in Medi-Cal, you will need to complete this form each year to verify your continued eligibility and maintain your benefits.

Understanding these documents can empower you to navigate the Medi-Cal system more effectively. Each form serves a unique purpose, and being familiar with them can help ensure that you and your family receive the healthcare services you need without unnecessary delays. If you have questions about any of these forms, don't hesitate to reach out for assistance.

Similar forms

The Medical Choice form is similar to several other documents that serve related purposes in healthcare enrollment and decision-making. Below is a list of these documents and their similarities:

  • Health Insurance Enrollment Form: This form collects personal information and health plan preferences, much like the Medical Choice form. It ensures that individuals can select their desired health coverage.
  • Medicaid Application: Similar to the Medical Choice form, this application gathers information to determine eligibility for Medicaid benefits. Both documents require personal and household details.
  • Provider Directory: This document provides information on available healthcare providers and their codes. It is referenced in the Medical Choice form to assist applicants in selecting a plan and provider.
  • Change of Address Form: Like the Medical Choice form, this document is used to update personal information. It ensures that healthcare providers have the correct contact details for effective communication.
  • Consent for Treatment Form: This form, similar to the Medical Choice form, requires signatures to authorize healthcare services. Both documents emphasize the importance of informed consent in healthcare decisions.
  • Health Plan Disenrollment Form: This document allows individuals to opt out of a health plan. It parallels the Medical Choice form by addressing changes in healthcare preferences and needs.

Dos and Don'ts

When filling out the Medical Choice form, there are several important guidelines to follow. Adhering to these recommendations can help ensure that your application is processed smoothly.

  • Print Clearly: Use a blue or black pen and write legibly to avoid any confusion.
  • Complete All Sections: Ensure that all required information for each household member receiving Medi-Cal is filled out completely.
  • Use the Correct Plan Codes: If selecting a health plan, make sure to include the correct doctor or clinic code from the Provider Directory.
  • Contact for Additional Forms: If your household has more than three members, call the provided number to request more forms.
  • Sign Where Required: Ensure that all necessary signatures are provided, especially for applicants under 18, where a parent or guardian must sign.
  • Mail to the Correct Address: Double-check that you are sending the completed form to the specified address to avoid delays.

Conversely, there are also actions to avoid when completing this form:

  • Do Not Leave Blank Spaces: Incomplete forms can lead to processing delays or rejection.
  • Avoid Using Pencil: Always use a pen to ensure that your information is clear and permanent.
  • Do Not Forget to Read Instructions: Failing to understand the requirements can result in errors.
  • Do Not Submit Multiple Forms: Only submit one form per household unless instructed otherwise.
  • Do Not Ignore Deadlines: Ensure that your form is submitted within any specified timeframes to avoid losing eligibility.
  • Do Not Include Unnecessary Information: Stick to the information requested on the form to keep it concise and relevant.

Misconceptions

Misconceptions about the Medical Choice form can lead to confusion and errors in the enrollment process. Here are seven common misconceptions explained:

  • It is optional to fill out both sides of the form. Many believe they can skip one side. However, completing both sides is essential for proper processing.
  • Only the head of household needs to fill out the form. In reality, every person in the household receiving Medi-Cal must be included. This ensures accurate enrollment for all members.
  • Choosing a health plan is a straightforward process. Some think it is as simple as checking a box. In fact, it requires careful consideration of available options and potential provider networks.
  • Once submitted, the choice of health plan cannot be changed. This is not true. Members can change their health plan under certain circumstances, such as moving or dissatisfaction with their current plan.
  • All health plans offer the same services. This misconception overlooks the fact that different plans may have varying benefits, coverage options, and provider networks.
  • Filling out the form incorrectly will not affect enrollment. Errors can lead to delays or denial of coverage. It is crucial to ensure all information is accurate and complete.
  • Help is not available for filling out the form. In fact, assistance is readily available by calling the provided helpline, making the process easier for those who need support.

Key takeaways

Filling out the Medical Choice form is a crucial step for families seeking Medi-Cal health coverage. Here are some key takeaways to ensure a smooth experience:

  • Complete Both Sides: Make sure to fill out both sides of the form. This ensures that all necessary information is captured for processing.
  • Use the Right Tools: Print clearly using a blue or black pen. This helps prevent any misunderstandings due to illegible handwriting.
  • Include All Household Members: Provide information for each person in your household who is eligible for Medi-Cal. This is essential for accurate enrollment.
  • Seek Help If Needed: If you have questions or need assistance, don’t hesitate to call 1-800-430-4263. Free help is available for filling out the form.
  • Know Your Plan Options: Familiarize yourself with the different health plans available. Choose the one that best meets your family’s needs and fill in the corresponding code from the Provider Directory.
  • Sign and Date: Ensure that the form is signed and dated by the head of the household and any applicants under 18. This step is vital for the form to be valid.

By keeping these points in mind, families can navigate the Medical Choice form with greater confidence and ease.