Member Forms and Brochures

Instructions to complete the reimbursement form for
Over-the-Counter (OTC) COVID-19 tests

• Medical Claim Form for Group and Individual & Family Plans – English (PDF)
• Medical Claim Form for Group and Individual & Family Plans – En Español (Spanish) (PDF)

Important: Complete a separate form for each member asking for reimbursement for covered services and for each doctor and/or facility. To avoid processing delays, please include the following information with this form:

• Copy of itemized bill showing all services received. Must include name, address, phone number, tax ID number of doctor and/or facility, date of service and all diagnosis and procedure codes.
• Proof of payment for reimbursement requests over $200. "Proof of Payment" includes: a copy of the credit card charge slip or online statement, canceled checks, a bank account statement, cash withdrawal slips, or a cruise ship statement. Note: Invoices are not acceptable proof of payment.
• See the instructions in Section 4 for Foreign Claim Questionnaire for services received outside of the U.S

Other Forms

• Medicare – Medical – MHN Claim Form & Foreign Claim Questionnaire – English (PDF)
• Non-Medicare – Behavioral Health (MHN) – Claim Form – English (PDF)
• IFP and Group Member Grievance Form – English (PDF)
• IFP and Group Member Grievance Form – Chinese (PDF)
• IFP and Group Member Grievance Form – En Español (Spanish) (PDF)

Please explain in detail the circumstances that led to your dissatisfaction with Health Net. Please include the original copy of any claims or bills received which are related to your issue.

• Dental Claim Form – English (PDF)
• Medicare Supplement Plan Claims
• Out-of-Network Vision Claim Form (non-Medicare) – English (PDF)

• Foreign Claims Questionnaire – English (PDF)
• Foreign Claims Questionnaire – En Español (Spanish) (PDF)

For Healthy Families, Healthy Kids and AIM plan members. Medi-Cal members please contact Member Services.

Small Group

• Small Group Enrollment/Change Form – English (PDF)
• Small Group Enrollment/Change Form – En Español (Spanish) (PDF)
• Small Group Enrollment/Change Form – Chinese (PDF)
• Small Group Enrollment/Change Form – Korean (PDF)
• Small Group Enrollment/Change Form – Vietnamese (PDF)

Large Group

• Large Group Enrollment/Change Form – English (PDF)
• Large Group Enrollment/Change Form – En Español (Spanish) (PDF)
• Large Group Enrollment/Change Form – Chinese (PDF)
• Large Group Enrollment/Change Form – Korean (PDF)
• Large Group Enrollment/Change Form – Vietnamese (PDF)

Employee/Dependent Enrollment Forms

• Health Net Life Group Employee/Dependent Enrollment Form – English (PDF)
• Health Net Life Group Employee/Dependent Enrollment Form – En Español (Spanish) (PDF)

Pre-enrollment Material

• Welcome Letter – English (PDF)
• Choice Form Flyer – English (PDF)

Post-enrollment Material

• Welcome Letter – English (PDF)
• Welcome Booklet – English (PDF)
• Health Information Form Flyer – English (PDF)
• Health Information Form Flyer – En Español (Spanish) (PDF)
• How To Get Care – English (PDF)
• Telehealth Flyer – English (PDF)
• Preventive Care Services (ACA Non-Grandfathered Plans) – English (PDF)
• Preventive Care Services (ACA Non-Grandfathered Plans) – En Español (Spanish) (PDF)
• Healthy Smiles – English (PDF)
• Health Education Services Flyer – English (PDF)
• Community Resource Center Flyer – English (PDF)

First Health Provider Nomination Form – English (PDF)

You can save a lot by using a doctor who participates in the First Health Network. That's why we make it easy for you to nominate him or her to join.

• Continuity of Care Assistance Request Form – English (PDF)
• Continuity of Care Assistance Request Form – En Español (Spanish) (PDF)
• Disabled Dependent Certification Form – English (PDF)
• MPX flyer for Commercial Members – English (PDF)
• MPX flyer for Commercial Members – En Español (Spanish) (PDF)
• MPX flyer for Ambetter Members – English (PDF)
• MPX flyer for Ambetter Members – En Español (Spanish) (PDF)
• MPX flyer for Medi-Cal Members – English (PDF)
• MPX flyer for Medi-Cal Members – En Español (Spanish) (PDF)

Mail Order Pharmacy

• CVS Caremark Mail Order Pharmacy – English (PDF)
• CVS Caremark Mail Order Pharmacy – En Español (Spanish) (PDF)

Prescription Claims

• Prescription Drug Claim Form (Commercial Members) – English (PDF)
• Prescription Drug Claim Form (Commercial Members) – En Español (Spanish) (PDF)

Prescription Transition Form

• Prescription Transition Form (Commercial Members) – English (PDF)
• Prescription Transition Form (Commercial Members) – En Español (Spanish) (PDF)

Medicare materials

• Authorization For Disclosure of PHI - English (PDF)
• Authorization For Disclosure of PHI - En Español (Spanish) (PDF)
• Authorization For Disclosure of PHI - Chinese (PDF)
• Authorization For Disclosure of PHI - Korean (PDF)

• Authorization For Use or Disclosure of Medical Information - English (PDF)
• Authorization For Use or Disclosure of Medical Information - En Español (Spanish) (PDF)
• Authorization For Use or Disclosure of Medical Information - Arabic (PDF)
• Authorization For Use or Disclosure of Medical Information - Armenian (PDF)
• Authorization For Use or Disclosure of Medical Information - Cambodian (PDF)
• Authorization For Use or Disclosure of Medical Information - Chinese (PDF)
• Authorization For Use or Disclosure of Medical Information - Farsi (PDF)
• Authorization For Use or Disclosure of Medical Information - Hmong (PDF)
• Authorization For Use or Disclosure of Medical Information - Korean (PDF)
• Authorization For Use or Disclosure of Medical Information - Russian (PDF)
• Authorization For Use or Disclosure of Medical Information - Tagalog (PDF)
• Authorization For Use or Disclosure of Medical Information - Vietnamese (PDF)

HIPAA authorization forms required for requesting applicant and member medical records.

• Medi-Cal - GRIEVANCE FORM
• Medi-Cal Dental - GRIEVANCE FORM

• Continuity of Care - English (PDF)
• Continuity of Care - Arabic (PDF)
• Continuity of Care - Armenian (PDF)
• Continuity of Care - Cambodian (PDF)
• Continuity of Care - Chinese (PDF)
• Continuity of Care - Hmong (PDF)
• Continuity of Care - Farsi (PDF)
• Continuity of Care - Korean (PDF)
• Continuity of Care - Russian (PDF)
• Continuity of Care - En Español (Spanish) (PDF)
• Medi-Cal Continuity of Care - En Español (Spanish) (PDF)
• Continuity of Care - Tagalog (PDF)
• Continuity of Care - Vietnamese (PDF)

• Glossary of Health Coverage and Medical Terms - English (PDF)
• Glossary of Health Coverage and Medical Terms - En Español (Spanish) (PDF)
• Glossary of Health Coverage and Medical Terms - Chinese (PDF)
• Glossary of Health Coverage and Medical Terms - Navajo (PDF)
• Glossary of Health Coverage and Medical Terms - Korean (PDF)

Health insurance companies and group health plans are required to make available a uniform glossary of health coverage and medical terms commonly used in plan documents. The Uniform Glossary is meant to help the consumer understand some of the most common language used in health insurance documents. Please log in to request a hardcopy of the document by mail.