CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan)

2019 Member Forms

Advanced Health Care Directive Appointment of Representative Form CareAdvantage Determination Request Form CareAdvantage Redetermination Request Form CareAdvantage Provider Directory Request Form Confidential Member Complaint Form PCP Selection and Address Change Form Protected Health Information Request Form

Instrucción anticipada de atención de salud de California Nombramiento de un Representante CareAdvantage CMC Directorio de proveedores formulario de solicitud Formulario de queja confidencial del miembro Cambio de doctor y de domicilio

Paunang Tagubilin ukol sa Pangangalaga sa Kalusugan Pagtalaga ng Kinatawan CareAdvantage CMC Direktoryo ng Tagabigay ng serbisyo ng Inyong Plano Humiling Form Form para sa Kumpidensiyal na Reklamo ng Miyembro Pangunahing Tagapangalagang and Pagbabago ng Address

Предварительные медицинские указания для жителей штата Калифорния Назначение представителя CareAdvantage CMC Запросить форму каталога поставщиков медицинских услуг Бланк жалобы для конфиденциального обращения участника Форма выбора основного лечащего врача смены адреса

Request a Printed Copy

If you would like a provider directory mailed to you, please send an email to providerdirectoryrequests@hpsm.org with the following information:

Your first and last name
Daytime phone number (in case we need to call you about your request)
Mailing address
Which directory you are requesting (HealthWorx HMO, ACE, CareAdvantage CMC, Healthy Kids HMO, or Medi-Cal)

CareAdvantage Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations and restrictions may apply. For more information, call the CareAdvantage Unit or read the CareAdvantage Member Handbook.

Benefits and co-pays may change on January 1 of each year.

If you speak other languages other than English, language assistance services, free of charge, are available to you. Call 1-866-880-0606 (TTY: 1-800-735-2929). (Download this statement in multiple languages.)

H7885_MMP_15129_01_19_EN_M Accepted

Page updated January 01, 2019