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Vaccine Screening & Information
Health Care Options (to change Medi-Cal health plans)
Fill-in and print the Heath Plan Change form here.
Please ensure you fill-in the below information on-line (before printing):
- Fill-in responsible adult’s information in top two lines
- Each child’s first and last names, gender and social security number
- Pick ”I wish to join or change my plan to:”
- Pick ONE of the two buttons either “029 Community Health Group Partner” OR “068 Health Net Comm Solutions”
- Specify Doctor Code for one (of 3) doctors for that child (samples above)
- Specify reason code “1″ for each child (continue with current doctor)
Please ensure all fields (arrows, underlines) are filled-in and signed, and mail to California DHCS at:
Health Care Options
P.O. Box 989009
W. Sacramento, CA 95798-9850