Patient Forms

Choose a sub-menu from below to find useful forms..

New Patient

Medical History

Transfer of Records

Consent/Refusal to Treat

Vaccine Screening & Information

Staying Healthy

Newborn Care

HIPAA

Arbitration Agreement

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