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Advance Health Care Directive/Durable Power of Attorney

The Advance Health Care Directive gives someone you chose the power to make decisions about your medical care in the event that you become too sick to make them yourself. HPSM recommends that everyone appoint durable power of attorney to someone they trust. To do that, fill out Part 1 of the Advanced Health Care Directive, have it notarized and follow the instructions on the last page.

This form is also available in Spanish (Español), Chinese (中文), Tagalog and Russian (русский) below.

Appoint a Representative

You have the right to appoint someone to represent you in medical matters (such as a family member, friend or other trusted person). A representative can contact HPSM on your behalf, get information about your benefits and make decisions about your medical care. If someone contacts HPSM claiming to be your representative, we will check our records to confirm their status before sharing your health information or taking any action.

Appointment of Representative Form

This form is also available in Spanish (Español), Chinese (中文), Tagalog and Russian (русский) below.

CareAdvantage Enrollment Form

To join CareAdvantage D-SNP please complete and return the enrollment form. Eligible members must have Medicare Part A, Medicare Part B, and Medi-Cal through the Health Plan of San Mateo. If you are not a native English speaker, you can call 1-888-252-3153 to get the form in a different language.

CareAdvantage D-SNP Enrollment Form

This form is also available in Spanish (Español), Chinese (中文), and Tagalog below. 

CareAdvantage Disnrollment Form

CareAdvantage Disenrollment Form

This form is also available in Spanish (Español), Chinese (中文), and Tagalog below.

To complete this form, provide your personal information, including your full name, ID number, date of birth, gender, and phone number as requested. Be sure to sign and date the form. If you have an authorized representative, as recognized by state laws, they can complete the form on your behalf. Your representative will need to provide their information and sign as well. Once your form is processed, you will receive a confirmation letter with your effective date of disenrollment.

You can return this form to HPSM in three ways:

1. Mail:
   Health Plan of San Mateo
   Attention: CareAdvantage Unit
   801 Gateway Blvd., Suite 100
   South San Francisco CA 94080
   or
   
2. Email: Photograph or scan each page and send as an attachment to CareAdvantageSupport@hpsm.org
   or
   
3. Fax: 650-616-2190

How do I get help with this form?

If you have questions or require assistance, please contact the CareAdvantage Unit.

CareAdvantage Unit

Toll free: 1-866-880-0606
Local: 650-616-2174
TTY: 1-800-735-2929 or dial 7-1-1

Phone hours: Monday–Sunday 8:00 a.m. to 8:00 p.m.
Office hours: Monday–Friday 8:00 a.m. to 4:00 p.m.
Email: CareAdvantageSupport@hpsm.org

Choose a New PCP

No matter how long you’ve been an HPSM member, you can choose a new PCP. You can have the same PCP for all your family members or a different PCP for each person (e.g., children).

There are two ways you can change or choose a new PCP:

1. Log in to the Member Portal
2. Fill out the Primary Care Provider Change Form and return it to HPSM

Direct Member Reimbursement Form

Medi-Cal or CareAdvantage member should not receive bills from providers. If you paid for covered services, you can ask HPSM to pay you back. To request reimbursement, fill out and return the Direct Member Reimbursement (DMR) Claim Form and return it to HPSM with the required proof of payment.

This form is also available in Spanish (Español), Chinese (中文), Tagalog and Russian (русский) below.

Health Records Request Form

Fill-out and return the Protected Health Information Request Form to authorize the release of your health information.

Protected Health Information Request Form

Health Risk Assessment (HRA) Form

For Pediatric Medi-Cal and CareAdvantage Members

Your HRA tells HPSM and your providers what kind of care you need to stay as healthy as possible. It only takes about 20 minutes to complete, but it can have a big impact on your health. That’s because HPSM’s Care Coordination team uses the HRA to create your personalized Care Plan. You and your providers will get a copy of your Care Plan, which can be adjusted to your needs.

HPSM will call you to complete the HRA over the phone. You may also ask to get the survey by mail, so you can fill it out yourself and mail it back to HPSM. If you want to see the HRA questions before your call, click on the link below. If you have questions about the HRA, please call:

This form is also available in Spanish (Español), Chinese (中文), Tagalog and Russian (русский) below.

Member Complaint Form

Use this confidential form to submit a written complaint to HPSM. This form is optional. You may also file a complaint by calling us or visiting our office to speak face-to-face with a representative.

Confidential Member Complaint Form

This form is also available in Spanish (Español), Chinese (中文), Tagalog and Russian (русский) below.

Search for a provider

Use the online provider search form to find the latest information for in-network primary care providers (PCP), specialists, pharmacies, clinics or hospitals. This directory is updated weekly.  You may need a referral from your PCP before making an appointment with a specialist for non-emergency care. Call your PCP to find out if a referral is required.