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 loved ones

At some point during your care, you may want us to disclose your protected health information to someone else, like a partner or child. Here you’ll find the form you’ll need to authorize the release of that information.


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.


Primary care physician selection form

You can use this form to select or change your Primary Care Physician.


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.


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. Find out if you qualify and learn how to submit a request.


Request continuity of care benefits

To help your healthcare providers coordinate the best possible care for you, you can authorize your medical information and history to be integrated into one place that your providers can easily access. See how continuity of care benefits can improve your overall health care experience.

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 requests. Please fax the following completed form to 1.858.357.2534. 


Quick change form

Use this form to cancel your existing policy or update your name or address.


Covered CA Coverage Termination Form

Please complete this form if you would like to cancel your existing policy purchased through Covered California. You can submit the form by email, fax or mail.


Not finding what you’re looking for?

Let’s talk. Call us at 1.800.359.2002 or send us a message

FBT: no longer supports this Internet browser. For the best experience on our website, please upgrade your browser to the latest version.