The following are the forms available for members:
General Forms
- Employee Enrollment/Change Form (English)
- Employee Enrollment/Change Form (Spanish)
- Employee Enrollment/Change Form (With Vision)
- Individual Waiver Statement
- Individual Waiver Statement with Vision and SME
- COBRA Election Enrollment Form
- Dentist Nomination Form
- Dental Claim Form
- HIPAA Authorization (English)
- HIPAA Authorization (Spanish)
- Grievance Form – PPO
- Grievance Form – DHMO (English)
- Grievance Form – DHMO (Spanish)
- Grievance Form – DHMO (Chinese)
- Notice of Privacy Practices (English)
- Notice of Privacy Practices (Spanish)
- Language Assistance Services
- Grievance, Appeal and IMR insert
- Timely Access Annual Notice
Sacramento Geographic Managed Care Forms
- Sacramento Evidence of Coverage
- HIPAA Authorization (English)
- HIPAA Authorization (Spanish)
- HIPAA Authorization (Chinese)
- Grievance Form (English)
- Grievance Form (Spanish)
- Grievance Form (Chinese)
- Grievance Form (Vietnamese)
- Grievance Form (Russian)
- Notice of Privacy Practices (English)
- Notice of Privacy Practices (Spanish)
- Language Assistance Services
- Your Rights – Notice of Adverse Benefit Determination
- Your Rights – Notice of Appeal Resolution
- CA Medi-Cal Annual Notification
- ADP Nondiscrimination Notice and Tagline Government Programs
Los Angeles Pre-Paid Health Plan Forms
- Los Angeles Evidence of Coverage
- HIPAA Authorization (English)
- HIPAA Authorization (Spanish)
- HIPAA Authorization (Chinese)
- Grievance Form (English)
- Grievance Form (Spanish)
- Grievance Form (Chinese)
- Grievance Form (Vietnamese)
- Grievance Form (Russian)
- Notice of Privacy Practices (English)
- Notice of Privacy Practices (Spanish)
- Language Assistance Services
- Your Rights – Notice of Adverse Benefit Determination
- Your Rights – Notice of Appeal Resolution
- CA Medi-Cal Annual Notification
- ADP Nondiscrimination Notice and Tagline Government Programs
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