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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 CMC 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 Enrollment Form

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


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 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 30 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's partner, Independent Living Systems (ILS), will call you to complete the HRA over the phone. You may also ask to get the survey by mail. Then you can fill it out yourself and mail it back to HPSM. If you want to see the HRA questions before your call with ILS, click on the link below. If you have questions about the HRA, call 1-888-234-6403 (toll free) or 650-227-4670 between 8am and 5pm. 

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.

  •  Search by provider name, health plan, location or type of provider
  •  Click on a provider's name in the search results to see additional information
  •  Search results include links to interactive maps and directions
  •  Print or save the information for individual providers
  •  Weekly updates ensure you get the most accurate results

Update your address or phone number

There are two ways you can report a new address or phone number:

  1. Log in to the Member Portal
  2. Fill out the Member Change of Address Form and return it to HPSM

Medi-Cal and CareAdvantage members

If you move and/or change your contact information (phone number, email), you must tell both HPSM and either the Human Services Agency (HSA) or Social Security Administration (SSA). This will ensure that you continue to get important information about your Medi-Cal coverage status.

  • Medi-Cal members: Call HPSM Member Services (see contact information at right)
  • CareAdvantage members: Call the CareAdvantage Unit (see contact information at right)
  • Human Services Agency: Call 1-800-223-8383 or FAX the information to 650-620-9732
  • Social Security Administration: Call 1-800-772-1213 

Forms in Alternate Languages

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