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All the information you need, in one place

You can get the information and care that you need quickly with these commonly-requested forms.


Share your health information with family

At some point during your care, you may want us to disclose your protected health information (PHI) to someone else, like your spouse or child. Here you’ll find the information you’ll need to authorize the release of health information.

FIND OUT MORE ➜

Request a deductible credit

If you’ve recently changed health insurance providers, you may be eligible to receive a credit for money applied toward your deductible with your previous health plan. Find out if you qualify and learn how to request a deductible credit.

LEARN MORE ➜

Primary care physician selection form

You can use this form to select or change your primary care physician.

LEARN MORE ➜

Get reimbursed for medical services

If you're looking to be reimbursed for eligible out-of-pocket medical expenses, be sure to submit this reimbursement request form within 180 days of the date of service.

DOWNLOAD FORM ➜

Get reimbursed for your prescription drugs

If your doctor has prescribed a medication you’ve purchased from a pharmacy within the last 180 days, then you might be eligible for a reimbursement.

Use the 2019 reimbursement form for pharmacy services rendered before Jan. 1, 2020.

DOWNLOAD 2020 FORM (PDF) ➜

Request continuity of care benefits

Continuity of care means continued services, under certain conditions, with your current health care provider until your provider completes your care. Find out if you qualify and learn how to submit a request by visiting the webpage.

 

MORE ABOUT CONTINUITY OF CARE ➜

Pharmacy pre-authorization form

Regulations may require pharmacies to get prior authorization before dispensing certain medications. Here's the form your prescriber will need to complete these requests, including those for step therapy. Fax the following form to 1-888-836-0730 (or 1-855-245-2134 for Covered California members).

DOWNLOAD FORM ➜

Change your plan

Fill out this form if you would like to make changes to, or update the personal information associated with, your individual and family plan.

Covered California® members: call 1-800-300-1506 or update your account online at coveredca.com.

DOWNLOAD CHANGE FORM ➜

Termination form

Please complete this form if you would like to cancel your individual and family plan. Then submit the form by mail, in person, or by fax.

DOWNLOAD TERMINATION FORM ➜

Not finding what you’re looking for?

Let’s talk. Call us at 1-800-359-2002 or send us a message

We’re here to answer any of your questions