CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 2025

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 Adult Health Risk Assessment (HRA) Form Member Change of Address Form Primary Care Provider Change Form CareAdvantage D-SNP Enrollment Form CareAdvantage Disenrollment Form

Cuidado Médico por Adelanto de California Nombramiento de un Representante CareAdvantage Directorio de proveedores formulario de solicitud Formulario de queja confidencial del miembro CareAdvantage Evaluación de Riesgos para la Salud (HRA) Formulario de cambio de dirección Formulario de cambio de proveedor de atención primaria CareAdvantage D-SNP Formulario de Inscripción CareAdvantage formulario de cancelación de membresía

加州預立醫療指示任命代表 CareAdvantage 您的計劃的服務提供者名錄申請表保密會員投訴表 CareAdvantage 健康風險評估 (HRA) 地址變更表單初級保健提供者 (PCP) 變更表單 CareAdvantage D-SNP 註冊表格 CareAdvantage 退出計劃申請表

Direksyon sa Pangangalaga sa Kalusugan ng Advance Pagtalaga ng Kinatawan CareAdvantage Direktoryo ng Tagabigay ng serbisyo ng Inyong Plano Humiling Form Form para sa Kumpidensiyal na Reklamo ng Miyembro CareAdvantage Pagtatasa ng Panganib sa Kalusugan (HRA) Form Form sa Pagpapalit ng Address Form sa Pagpapalit ng Provider ng Pangunahing ng Pangangalaga (PCP) CareAdvantage D-SNP Form sa Pagpapalista Form para sa pagkakatanggal mula sa pagkaka-Enroll

Информация о предварительном медицинском указании для штата НАЗНАЧЕНИЕ ПРЕДСТАВИТЕЛЯ CareAdvantage Запросить форму каталога поставщиков медицинских услуг Бланк жалобы для конфиденциального обращения участника Изменение адресной формы Форма смены основного поставщика медицинских услуг (PCP)

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 want (CareAdvantage or Medi-Cal)

CareAdvantage Dual Eligible Special Needs Plan (D-SNP) 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 D-SNP 2025 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 or dial 7-1-1). ( Download this statement in multiple languages.)

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Page updated November 1, 2024

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