This Member Forms page is where you can access different requests, disclosures and authorizations. These forms can assist you with how to request copies of documents or materials, authorize someone else to speak on your behalf, and request Health Plan’s services. Please note that forms cannot be completed online. You will need to print out the form(s), complete all sections, and mail or fax back to Health Plan.
This form will allow adult members to give access to any other person to speak/act in their behalf with Health Plan staff. This form may also be used by parents who would like to grant access to another individual to speak/act in behalf of their own minor member/child.
You will need to print out the form, complete all sections, and mail or fax back via mail or fax.
Mail:
Health Plan
ATTN: Customer Service
7751 S. Manthey Road
French Camp, CA 95231
Fax: (209) 461-2550
Note: To request this form in a different language, please contact Customer Service at (209) 942-6320
This form allows family members access to speak/act in in behalf of a minor member with Health Plan staff in the absence of parents and/or legal guardians in the absence of legal court issued documents including guardianship letters.
Family members are: spouse, parent, stepparent, brother, sister, stepbrother, stepsister, half-brother, half-sister, uncle, aunt, niece, nephew, first cousin, or any person with a prefix of “grand” or “great”, or the spouse of any of the family members listed above.
You will need to print out the form, complete all sections, and mail or fax back via mail or fax.
Mail:
Health Plan
ATTN: Customer Service
7751 S. Manthey Road
French Camp, CA 95231
Fax: (209) 461-2550
Note: To request this form in a different language, please contact Customer Service at (209) 942-6320
This form will allow members to request access to their own member health records or materials from Health Plan for personal viewing or to be shared with someone else on their behalf. Information that may be requested includes enrollment, payment, claims, and medical or case management records.
You will need to print out the form, complete all sections, and mail or fax back via mail or fax.
Mail:
Health Plan
ATTN: Customer Service
7751 S. Manthey Road
French Camp, CA 95231
Fax: (209) 461-2550
Note: To request this form in a different language, please contact Customer Service at (209) 942-6320
Posted on August 2nd, 2021 and last modified on October 1st, 2024.
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